Basic Information
| Provider Information | |||||||||
| NPI: | 1881649655 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | POLSON | ||||||||
| FirstName: | AIDA | ||||||||
| MiddleName: | R | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 777 AVENUE H | ||||||||
| Address2: | |||||||||
| City: | POWELL | ||||||||
| State: | WY | ||||||||
| PostalCode: | 82435 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3077547257 | ||||||||
| FaxNumber: | 3078575215 | ||||||||
| Practice Location | |||||||||
| Address1: | 777 AVENUE H | ||||||||
| Address2: | |||||||||
| City: | POWELL | ||||||||
| State: | WY | ||||||||
| PostalCode: | 824352260 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3077547257 | ||||||||
| FaxNumber: | 3077547730 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/23/2006 | ||||||||
| LastUpdateDate: | 03/23/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | M-9474 | ID | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | 7734A | WY | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1881649655 | 05 | WY | MEDICAID |