1750779039 NPI number — TRAVIS A YOUNG NP-C

Table of content: TRAVIS A YOUNG NP-C (NPI 1750779039)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1750779039 NPI number — TRAVIS A YOUNG NP-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
YOUNG
Provider First Name:
TRAVIS
Provider Middle Name:
A
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
NP-C
Provider Gender Code:
M

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:
1750779039
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/26/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3008 E PARK AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BRUNSWICK
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
31520-4241
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
912-265-2142
Provider Business Mailing Address Fax Number:
912-265-0530

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
114 NORTHPARK DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BRUNSWICK
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
31520-2184
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
912-268-4471
Provider Business Practice Location Address Fax Number:
912-771-8053
Provider Enumeration Date:
01/08/2015

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: 363LF0000X , with the licence number:  2014039709 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363L00000X , with the licence number: RN274244 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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