Provider Demographics
NPI:1407951015
Name:YOUNG, KATHERINE E (PA-C)
Entity Type:Individual
Prefix:
First Name:KATHERINE
Middle Name:E
Last Name:YOUNG
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2270 JOLLY OAK RD STE 1
Mailing Address - Street 2:
Mailing Address - City:OKEMOS
Mailing Address - State:MI
Mailing Address - Zip Code:48864-6932
Mailing Address - Country:US
Mailing Address - Phone:517-975-9475
Mailing Address - Fax:517-975-9490
Practice Address - Street 1:2270 JOLLY OAK RD STE 1
Practice Address - Street 2:
Practice Address - City:OKEMOS
Practice Address - State:MI
Practice Address - Zip Code:48864-6932
Practice Address - Country:US
Practice Address - Phone:517-975-9475
Practice Address - Fax:517-975-9490
Is Sole Proprietor?:No
Enumeration Date:2006-09-14
Last Update Date:2019-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601005696363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL292449800Medicaid
FLPA9102891OtherMEDICAL LICENSE #
FLPA9102891OtherMEDICAL LICENSE #