Provider Demographics
NPI:1033408141
Name:YOUNGBERG, MARK (MS-IV)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:YOUNGBERG
Suffix:
Gender:M
Credentials:MS-IV
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1959 NE PACIFIC ST
Mailing Address - Street 2:BOX 356540, BB-1440 HSB
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98195-6540
Mailing Address - Country:US
Mailing Address - Phone:206-543-2773
Mailing Address - Fax:206-543-2958
Practice Address - Street 1:1959 NE PACIFIC ST
Practice Address - Street 2:BOX 356540, BB-1440 HSB
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98195-6540
Practice Address - Country:US
Practice Address - Phone:206-543-2773
Practice Address - Fax:206-543-2958
Is Sole Proprietor?:No
Enumeration Date:2011-03-30
Last Update Date:2011-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program