Provider Demographics
NPI:1801866462
Name:POLANSKY, IRINA Y (PA-C)
Entity Type:Individual
Prefix:
First Name:IRINA
Middle Name:Y
Last Name:POLANSKY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:130 LINCOLN PLACE CT STE 130
Mailing Address - Street 2:
Mailing Address - City:BELLEVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62221-5884
Mailing Address - Country:US
Mailing Address - Phone:618-257-1297
Mailing Address - Fax:618-257-1529
Practice Address - Street 1:130 LINCOLN PLACE CT STE 130
Practice Address - Street 2:
Practice Address - City:BELLEVILLE
Practice Address - State:IL
Practice Address - Zip Code:62221-5884
Practice Address - Country:US
Practice Address - Phone:618-257-1297
Practice Address - Fax:618-277-1190
Is Sole Proprietor?:No
Enumeration Date:2006-01-25
Last Update Date:2021-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085002586363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILQ57884Medicare UPIN
ILIL3374019Medicare PIN