Provider Demographics
NPI:1679008379
Name:INDA, PRISCILLA STEPHANIE (PA-C)
Entity Type:Individual
Prefix:MS
First Name:PRISCILLA
Middle Name:STEPHANIE
Last Name:INDA
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MRS
Other - First Name:PRISCILLA
Other - Middle Name:STEPHANIE
Other - Last Name:LA BERGE-INDA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:429 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:CHULA VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:91910-4320
Mailing Address - Country:US
Mailing Address - Phone:619-434-0204
Mailing Address - Fax:619-337-0191
Practice Address - Street 1:429 BROADWAY
Practice Address - Street 2:
Practice Address - City:CHULA VISTA
Practice Address - State:CA
Practice Address - Zip Code:91910-4320
Practice Address - Country:US
Practice Address - Phone:619-434-0204
Practice Address - Fax:619-337-0191
Is Sole Proprietor?:No
Enumeration Date:2017-05-01
Last Update Date:2022-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA54404363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant