Basic Information
| Provider Information | |||||||||
| NPI: | 1578052882 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | POLSTON | ||||||||
| FirstName: | TRAVIS | ||||||||
| MiddleName: | ALEXANDER | ||||||||
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| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | POLSTON | ||||||||
| OtherFirstName: | T. | ||||||||
| OtherMiddleName: | ALEX | ||||||||
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| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 25608 | ||||||||
| Address2: | |||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841250608 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2063204476 | ||||||||
| FaxNumber: | 2065687043 | ||||||||
| Practice Location | |||||||||
| Address1: | 1401 MADISON ST STE 100 | ||||||||
| Address2: | |||||||||
| City: | SEATTLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981041316 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2063866111 | ||||||||
| FaxNumber: | 2063866113 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/02/2018 | ||||||||
| LastUpdateDate: | 11/10/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/10/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | MD.61161867 | WA | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | MD61161867 | WA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.