Provider Demographics
NPI:1871039727
Name:POLING, MAXWELL CLARK (PA-C)
Entity Type:Individual
Prefix:
First Name:MAXWELL
Middle Name:CLARK
Last Name:POLING
Suffix:
Gender:M
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 1:801 YORK ST
Mailing Address - Street 2:
Mailing Address - City:MANITOWOC
Mailing Address - State:WI
Mailing Address - Zip Code:54220-4630
Mailing Address - Country:US
Mailing Address - Phone:920-663-9008
Mailing Address - Fax:904-342-7770
Practice Address - Street 1:420 5TH AVE
Practice Address - Street 2:
Practice Address - City:INDIALANTIC
Practice Address - State:FL
Practice Address - Zip Code:32903-4280
Practice Address - Country:US
Practice Address - Phone:321-312-1352
Practice Address - Fax:321-312-1513
Is Sole Proprietor?:No
Enumeration Date:2017-01-17
Last Update Date:2023-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPAT9109932363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant