Basic Information
| Provider Information | |||||||||
| NPI: | 1659751105 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | POLOCHAK | ||||||||
| FirstName: | STEPHANIE | ||||||||
| MiddleName: | |||||||||
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| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | GONDEK | ||||||||
| OtherFirstName: | STEPHANIE | ||||||||
| OtherMiddleName: | |||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1101 26TH ST S | ||||||||
| Address2: | ANESTHESIA | ||||||||
| City: | GREAT FALLS | ||||||||
| State: | MT | ||||||||
| PostalCode: | 59405 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4064555000 | ||||||||
| FaxNumber: | 4067318318 | ||||||||
| Practice Location | |||||||||
| Address1: | 1101 26TH ST S | ||||||||
| Address2: | ANESTHESIA | ||||||||
| City: | GREAT FALLS | ||||||||
| State: | MT | ||||||||
| PostalCode: | 59405 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4064555000 | ||||||||
| FaxNumber: | 4067318318 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/30/2015 | ||||||||
| LastUpdateDate: | 03/17/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 03/17/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | 106621 | NC | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered | 367500000X | 185186 | MT | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
No ID Information.