Provider Demographics
NPI:1831624899
Name:POLO, LUIS (NP)
Entity type:Individual
Prefix:
First Name:LUIS
Middle Name:
Last Name:POLO
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1115 LEXINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31404-5502
Mailing Address - Country:US
Mailing Address - Phone:912-354-4813
Mailing Address - Fax:912-354-7569
Practice Address - Street 1:1115 LEXINGTON AVE
Practice Address - Street 2:
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31404-5502
Practice Address - Country:US
Practice Address - Phone:912-354-4813
Practice Address - Fax:912-354-7569
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-27
Last Update Date:2017-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN240427363L00000X, 163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse