Provider Demographics
NPI:1952039265
Name:POLANCO, ANGEL
Entity Type:Individual
Prefix:
First Name:ANGEL
Middle Name:
Last Name:POLANCO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3003 TRANSPORT ST SE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87106-4307
Mailing Address - Country:US
Mailing Address - Phone:575-770-6697
Mailing Address - Fax:
Practice Address - Street 1:105 BERTHA RD
Practice Address - Street 2:
Practice Address - City:TAOS
Practice Address - State:NM
Practice Address - Zip Code:87571-7148
Practice Address - Country:US
Practice Address - Phone:575-758-4297
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-13
Last Update Date:2023-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator