Provider Demographics
NPI:1679036644
Name:POLLEY, INDYANA
Entity Type:Individual
Prefix:
First Name:INDYANA
Middle Name:
Last Name:POLLEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1691 THE ALAMEDA
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95126-2203
Mailing Address - Country:US
Mailing Address - Phone:408-287-7526
Mailing Address - Fax:
Practice Address - Street 1:1431 MCHENRY AVE STE 100
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95350-4534
Practice Address - Country:US
Practice Address - Phone:209-579-2300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-08
Last Update Date:2022-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA57094363A00000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant