Provider Demographics
NPI:1043446222
Name:YOUNG, LISA ANN (DO)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:ANN
Last Name:YOUNG
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
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Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 860
Mailing Address - Street 2:WHITERIVER IHS
Mailing Address - City:WHITERIVER
Mailing Address - State:AZ
Mailing Address - Zip Code:85941
Mailing Address - Country:US
Mailing Address - Phone:928-338-4911
Mailing Address - Fax:928-338-5508
Practice Address - Street 1:1 MAGNOLIA CT
Practice Address - Street 2:
Practice Address - City:MOULTRIE
Practice Address - State:GA
Practice Address - Zip Code:31768-6764
Practice Address - Country:US
Practice Address - Phone:229-502-9769
Practice Address - Fax:928-338-5508
Is Sole Proprietor?:No
Enumeration Date:2009-06-02
Last Update Date:2021-10-05
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GA88683207Q00000X
COTL-3268207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ853249Medicaid
030113Medicare Oscar/Certification