Provider Demographics
NPI:1669401022
Name:YOUNG, POLLY JANE (NP)
Entity type:Individual
Prefix:MRS
First Name:POLLY
Middle Name:JANE
Last Name:YOUNG
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:POLLY
Other - Middle Name:J
Other - Last Name:PECK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:ANP
Mailing Address - Street 1:PO BOX 1250
Mailing Address - Street 2:99 EAST STATE STREET
Mailing Address - City:GLOVERSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:12078
Mailing Address - Country:US
Mailing Address - Phone:518-752-5275
Mailing Address - Fax:518-752-5277
Practice Address - Street 1:99 EAST STATE STREET
Practice Address - Street 2:
Practice Address - City:GLOVERSVILLE
Practice Address - State:NY
Practice Address - Zip Code:12078
Practice Address - Country:US
Practice Address - Phone:518-752-5275
Practice Address - Fax:518-752-5277
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-30
Last Update Date:2021-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY303481363L00000X
NYF303481363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02357431Medicaid
NY000403459002OtherBSH NE NY
NY696035OtherMVP HEALTHPLAN
NY000403459002OtherBSH NE NY
NYJ400216266Medicare PIN