Provider Demographics
NPI:1164457057
Name:YOUNG, BRANDON MARK (PT)
Entity Type:Individual
Prefix:MR
First Name:BRANDON
Middle Name:MARK
Last Name:YOUNG
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2121 E WILLIAMS ST
Mailing Address - Street 2:SUITE 108
Mailing Address - City:APEX
Mailing Address - State:NC
Mailing Address - Zip Code:27539-7764
Mailing Address - Country:US
Mailing Address - Phone:919-946-7011
Mailing Address - Fax:
Practice Address - Street 1:2121 E WILLIAMS ST
Practice Address - Street 2:SUITE 108
Practice Address - City:APEX
Practice Address - State:NC
Practice Address - Zip Code:27539-7764
Practice Address - Country:US
Practice Address - Phone:919-372-8412
Practice Address - Fax:919-267-6556
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-11
Last Update Date:2017-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9857174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC079K8OtherBCBS PROVIDER NUMBER