Provider Demographics
NPI:1023358751
Name:YOUNG, LARA RENEE (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:LARA
Middle Name:RENEE
Last Name:YOUNG
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2962 VINCENT RD
Mailing Address - Street 2:
Mailing Address - City:SILVER LAKE
Mailing Address - State:OH
Mailing Address - Zip Code:44224-2956
Mailing Address - Country:US
Mailing Address - Phone:330-414-9877
Mailing Address - Fax:
Practice Address - Street 1:150 CROSS ST
Practice Address - Street 2:
Practice Address - City:AKRON
Practice Address - State:OH
Practice Address - Zip Code:44311-1026
Practice Address - Country:US
Practice Address - Phone:330-996-9141
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-02-16
Last Update Date:2019-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLB640536866330363AM0700X
OH50.004965RX363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH219385Medicaid