Provider Demographics
NPI:1326760463
Name:YOUNG S. KEUM, FNP, INC
Entity Type:Organization
Organization Name:YOUNG S. KEUM, FNP, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING AGENT
Authorized Official - Prefix:
Authorized Official - First Name:JOSHUA
Authorized Official - Middle Name:TAYLOR
Authorized Official - Last Name:WIGGINS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-498-7736
Mailing Address - Street 1:PO BOX 16793
Mailing Address - Street 2:
Mailing Address - City:SOUTH LAKE TAHOE
Mailing Address - State:CA
Mailing Address - Zip Code:96151-6793
Mailing Address - Country:US
Mailing Address - Phone:530-545-8782
Mailing Address - Fax:
Practice Address - Street 1:1001 PYRAMID WAY STE 206
Practice Address - Street 2:
Practice Address - City:SPARKS
Practice Address - State:NV
Practice Address - Zip Code:89431-4470
Practice Address - Country:US
Practice Address - Phone:775-710-8380
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-09-15
Last Update Date:2022-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty