1770571820 NPI number — AMY MARIE YOUNG PA-C

Table of content: AMY MARIE YOUNG PA-C (NPI 1770571820)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770571820 NPI number — AMY MARIE YOUNG PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
YOUNG
Provider First Name:
AMY
Provider Middle Name:
MARIE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA-C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1770571820
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/21/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
645 E MISSOURI AVE STE 300
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PHOENIX
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85012-1351
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
602-262-8900
Provider Business Mailing Address Fax Number:
602-262-8890

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6780 W THUNDERBIRD RD STE A105
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PEORIA
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85381
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
602-595-0525
Provider Business Practice Location Address Fax Number:
602-595-2470
Provider Enumeration Date:
10/12/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363A00000X , with the licence number:  5601003682 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363A00000X , with the licence number: 4872 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 139497 . This is a "GREAT LAKES HEALTH PLAN" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 275 . This is a "COMMUNITY CHOICE" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 1010619 . This is a "MCLAREN HEALTH PLAN" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 970025690 . This is a "RAILROAD MEDICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 3500576 . This is a "MOLINA HEALTH CARE" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 1010619 . This is a "MCLARENHEALTHADVANTAGE" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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