Provider Demographics
NPI:1104835768
Name:YOUNG, LEANN B (PAC)
Entity Type:Individual
Prefix:MRS
First Name:LEANN
Middle Name:B
Last Name:YOUNG
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8600 N ROUTE 91
Mailing Address - Street 2:SUITE 130
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61615
Mailing Address - Country:US
Mailing Address - Phone:309-683-5059
Mailing Address - Fax:309-683-5446
Practice Address - Street 1:8600 N ROUTE 91
Practice Address - Street 2:SUITE 130
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61615
Practice Address - Country:US
Practice Address - Phone:309-683-5059
Practice Address - Fax:309-683-5446
Is Sole Proprietor?:No
Enumeration Date:2006-08-05
Last Update Date:2008-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085001383363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL920006568OtherRAILROAD MEDICARE
ILP00608470OtherRR MEDICARE GROUP MEMBER PTAN
IL434110OtherMEDICARE GROUP
ILCA4079OtherRR MEDICARE GROUP PTAN
ILCA4079OtherRR MEDICARE GROUP PTAN
ILK51373Medicare PIN
ILL86618Medicare PIN