Provider Demographics
NPI:1821288788
Name:WISHON-SHAH, POLLY (AS,RT,R,M,CT,MR)
Entity Type:Individual
Prefix:MS
First Name:POLLY
Middle Name:
Last Name:WISHON-SHAH
Suffix:
Gender:F
Credentials:AS,RT,R,M,CT,MR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7460B E SAINT CHARLES RD
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65202-6801
Mailing Address - Country:US
Mailing Address - Phone:573-587-3426
Mailing Address - Fax:
Practice Address - Street 1:6451 N FEDERAL HWY
Practice Address - Street 2:SUITE 700
Practice Address - City:FT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33308-1402
Practice Address - Country:US
Practice Address - Phone:800-782-9029
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-27
Last Update Date:2007-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO276262247100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247100000XTechnologists, Technicians & Other Technical Service ProvidersRadiologic Technologist