Provider Demographics
NPI:1164590279
Name:YOUNG, JEFFREY LEE (PA)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:LEE
Last Name:YOUNG
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6400 FANNIN ST STE 1700
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77030-1526
Mailing Address - Country:US
Mailing Address - Phone:713-486-8200
Mailing Address - Fax:713-981-7106
Practice Address - Street 1:7789 SOUTHWEST FWY STE 540
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77074-1835
Practice Address - Country:US
Practice Address - Phone:713-486-8200
Practice Address - Fax:713-981-7106
Is Sole Proprietor?:No
Enumeration Date:2006-11-30
Last Update Date:2019-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX556120163WM0705X
TXPA02562363AM0700X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No163WM0705XNursing Service ProvidersRegistered NurseMedical-Surgical
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
S85320Medicare UPIN
TX8G5693Medicare ID - Type Unspecified