Provider Demographics
NPI:1790339893
Name:MARTELL POLO, ERNESTO (PA-C)
Entity type:Individual
Prefix:
First Name:ERNESTO
Middle Name:
Last Name:MARTELL POLO
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 1:16966 CAGAN RIDGE BLVD STE 220
Mailing Address - Street 2:
Mailing Address - City:CLERMONT
Mailing Address - State:FL
Mailing Address - Zip Code:34714-9656
Mailing Address - Country:US
Mailing Address - Phone:321-843-5851
Mailing Address - Fax:321-843-1673
Practice Address - Street 1:16966 CAGAN RIDGE BLVD STE 220
Practice Address - Street 2:
Practice Address - City:CLERMONT
Practice Address - State:FL
Practice Address - Zip Code:34714-9656
Practice Address - Country:US
Practice Address - Phone:321-843-5851
Practice Address - Fax:321-843-1673
Is Sole Proprietor?:No
Enumeration Date:2019-07-26
Last Update Date:2024-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9114867363A00000X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant