Provider Demographics
NPI:1457543258
Name:POLZIN, ALISIA KAY
Entity Type:Individual
Prefix:MRS
First Name:ALISIA
Middle Name:KAY
Last Name:POLZIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ALISIA
Other - Middle Name:KAY
Other - Last Name:BONE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1485 E 3900 S
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84124-1438
Mailing Address - Country:US
Mailing Address - Phone:801-277-2062
Mailing Address - Fax:801-274-3233
Practice Address - Street 1:1485 E 3900 S
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84124-1438
Practice Address - Country:US
Practice Address - Phone:801-277-2062
Practice Address - Fax:801-274-3233
Is Sole Proprietor?:No
Enumeration Date:2007-08-15
Last Update Date:2007-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT156798156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician