Provider Demographics
NPI:1265537021
Name:POLANDO, FREDERICK LEON (PA)
Entity type:Individual
Prefix:MR
First Name:FREDERICK
Middle Name:LEON
Last Name:POLANDO
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2234 COLONIAL BLVD
Mailing Address - Street 2:ATTN: PAYER CONTRACTING & RELATIONS DEPT.
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33907-1412
Mailing Address - Country:US
Mailing Address - Phone:239-931-7342
Mailing Address - Fax:239-931-7385
Practice Address - Street 1:580 BLACK RIVER RD
Practice Address - Street 2:
Practice Address - City:GEORGETOWN
Practice Address - State:SC
Practice Address - Zip Code:29440-3302
Practice Address - Country:US
Practice Address - Phone:843-652-4000
Practice Address - Fax:843-652-4004
Is Sole Proprietor?:No
Enumeration Date:2006-09-14
Last Update Date:2014-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA002186L363AM0700X
SCTL1940363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC5627895OtherAETNA
SC80026712OtherSELECT HEALTH
WV8600568OtherAETNA
WV2175863OtherUNITED HEALTHCARE
SCP01225399OtherRAILROAD MCR
WV8600568OtherAETNA
WVPO6030801Medicare PIN
SC5627895OtherAETNA