1730640954 NPI number — MR. DEREK SCOTT YOUNG JR. MEDICAL STUDENT

Table of content: MR. DEREK SCOTT YOUNG JR. MEDICAL STUDENT (NPI 1730640954)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1730640954 NPI number — MR. DEREK SCOTT YOUNG JR. MEDICAL STUDENT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
YOUNG
Provider First Name:
DEREK
Provider Middle Name:
SCOTT
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
JR.
Provider Credential Text:
MEDICAL STUDENT
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
STAMBAUGH
Provider Other First Name:
DEREK
Provider Other Middle Name:
SCOTT
Provider Other Name Prefix Text:
MR.
Provider Other Name Suffix Text:
JR.
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1730640954
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/29/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
DEPT. OF INTERNAL MEDICINE MSC 10-5550
Provider Second Line Business Mailing Address:
1 UNIVERSITY OF NEW MEXICO
Provider Business Mailing Address City Name:
ALBUQUERQUE
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
87131
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
505-272-6331
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
DEPT. OF INTERNAL MEDICINE MSC 10-5550
Provider Second Line Business Practice Location Address:
1 UNIVERSITY OF NEW MEXICO
Provider Business Practice Location Address City Name:
ALBUQUERQUE
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
87131
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
505-272-6331
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/29/2019

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: 390200000X , registered in the state of NM ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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