Provider Demographics
NPI:1033885363
Name:YOUNG, MYRA KATRINA
Entity Type:Individual
Prefix:
First Name:MYRA
Middle Name:KATRINA
Last Name:YOUNG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9215 CORINTHIAN CIR
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95826-2501
Mailing Address - Country:US
Mailing Address - Phone:916-598-2517
Mailing Address - Fax:
Practice Address - Street 1:9215 CORINTHIAN CIR
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95826-2501
Practice Address - Country:US
Practice Address - Phone:916-598-2517
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-17
Last Update Date:2021-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAD5717150172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver