Provider Demographics
NPI:1982763660
Name:POLASKI, GWENDOLYN A (PA)
Entity Type:Individual
Prefix:
First Name:GWENDOLYN
Middle Name:A
Last Name:POLASKI
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:GWENDOLYN
Other - Middle Name:A
Other - Last Name:ANDERSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:8100 34TH AVE S
Mailing Address - Street 2:21110Q
Mailing Address - City:BLOOMINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:55425-1672
Mailing Address - Country:US
Mailing Address - Phone:852-883-5790
Mailing Address - Fax:952-883-5395
Practice Address - Street 1:640 JACKSON STREET
Practice Address - Street 2:
Practice Address - City:ST PAUL
Practice Address - State:MN
Practice Address - Zip Code:55101-2502
Practice Address - Country:US
Practice Address - Phone:651-254-3456
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN10126363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
27271Medicare UPIN