Provider Demographics
NPI:1881649655
Name:POLSON, AIDA R (MD)
Entity Type:Individual
Prefix:
First Name:AIDA
Middle Name:R
Last Name:POLSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:777 AVENUE H
Mailing Address - Street 2:
Mailing Address - City:POWELL
Mailing Address - State:WY
Mailing Address - Zip Code:82435
Mailing Address - Country:US
Mailing Address - Phone:307-754-7257
Mailing Address - Fax:307-857-5215
Practice Address - Street 1:777 AVENUE H
Practice Address - Street 2:
Practice Address - City:POWELL
Practice Address - State:WY
Practice Address - Zip Code:82435-2260
Practice Address - Country:US
Practice Address - Phone:307-754-7257
Practice Address - Fax:307-754-7730
Is Sole Proprietor?:No
Enumeration Date:2006-05-23
Last Update Date:2016-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM-9474207R00000X
WY7734A207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY1881649655Medicaid
WY21516Medicare PIN
WY1881649655Medicaid