Provider Demographics
NPI:1760197743
Name:POLSON, BRENDON ISAAC IAN
Entity Type:Individual
Prefix:
First Name:BRENDON
Middle Name:ISAAC IAN
Last Name:POLSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:56 CLOVERFIELD CT
Mailing Address - Street 2:
Mailing Address - City:MIFFLINTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:17059-9033
Mailing Address - Country:US
Mailing Address - Phone:717-695-1564
Mailing Address - Fax:
Practice Address - Street 1:56 CLOVERFIELD CT
Practice Address - Street 2:
Practice Address - City:MIFFLINTOWN
Practice Address - State:PA
Practice Address - Zip Code:17059-9033
Practice Address - Country:US
Practice Address - Phone:717-695-1564
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-13
Last Update Date:2023-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA61387102163WC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC0200XNursing Service ProvidersRegistered NurseCritical Care Medicine