Provider Demographics
NPI:1003889577
Name:YOUNG, DOUGLAS TRENT (PAC)
Entity Type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:TRENT
Last Name:YOUNG
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 15645
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89114-5645
Mailing Address - Country:US
Mailing Address - Phone:702-242-7786
Mailing Address - Fax:702-240-8790
Practice Address - Street 1:2845 SIENA HEIGHTS DR
Practice Address - Street 2:
Practice Address - City:HENDERSON
Practice Address - State:NV
Practice Address - Zip Code:89052-4153
Practice Address - Country:US
Practice Address - Phone:702-617-1227
Practice Address - Fax:702-492-1589
Is Sole Proprietor?:No
Enumeration Date:2006-02-07
Last Update Date:2014-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVPA636363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV002402368Medicaid
NV1003889577Medicaid
NV101196Medicare PIN
S98086Medicare UPIN
NV1003889577Medicaid