Provider Demographics
NPI:1033638333
Name:YOUNG, WANDA RENEE (AGPCNP)
Entity Type:Individual
Prefix:
First Name:WANDA
Middle Name:RENEE
Last Name:YOUNG
Suffix:
Gender:F
Credentials:AGPCNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10901 TELEPHONE RD APT 44
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77075-4646
Mailing Address - Country:US
Mailing Address - Phone:832-409-9771
Mailing Address - Fax:713-987-5454
Practice Address - Street 1:3295 FM 3514
Practice Address - Street 2:
Practice Address - City:BEAUMONT
Practice Address - State:TX
Practice Address - Zip Code:77705-7655
Practice Address - Country:US
Practice Address - Phone:409-727-8400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-18
Last Update Date:2017-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX544145363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
00000000OtherNONE