Provider Demographics
NPI:1518996024
Name:YOUNG, RICKEY DALE (PA)
Entity Type:Individual
Prefix:
First Name:RICKEY
Middle Name:DALE
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 1:2872 S NC 127 HWY
Mailing Address - Street 2:
Mailing Address - City:HICKORY
Mailing Address - State:NC
Mailing Address - Zip Code:28602-9131
Mailing Address - Country:US
Mailing Address - Phone:828-330-2103
Mailing Address - Fax:828-294-0131
Practice Address - Street 1:2872 S NC 127 HWY
Practice Address - Street 2:
Practice Address - City:HICKORY
Practice Address - State:NC
Practice Address - Zip Code:28602-9131
Practice Address - Country:US
Practice Address - Phone:828-330-2103
Practice Address - Fax:828-294-0131
Is Sole Proprietor?:No
Enumeration Date:2006-06-30
Last Update Date:2018-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA3144363A00000X
NC0010-08118363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLQ41029Medicare UPIN
FLU4522ZMedicare PIN
P00313629Medicare PIN