Provider Demographics
NPI:1023130911
Name:RETZ, POLLY A (RN, CPNP)
Entity type:Individual
Prefix:
First Name:POLLY
Middle Name:A
Last Name:RETZ
Suffix:
Gender:F
Credentials:RN, CPNP
Other - Prefix:
Other - First Name:POLLY
Other - Middle Name:ANNE
Other - Last Name:RETZ-KRUCZKOWSKI
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:CPNP-PC
Mailing Address - Street 1:6210 E HWY 290 STE 240
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78723-1144
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11714 WILSON PARKE AVE STE 150
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78726-4061
Practice Address - Country:US
Practice Address - Phone:512-346-6611
Practice Address - Fax:512-406-6267
Is Sole Proprietor?:No
Enumeration Date:2007-04-04
Last Update Date:2024-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX587900363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX182838605Medicaid
TX182838606Medicaid
TX182838606Medicaid
TX182838605Medicaid
TXTXB118872Medicare PIN
TX8L1056Medicare PIN
TX500011853Medicare PIN
TXTXB118872Medicare PIN
TX182838603Medicaid