Provider Demographics
NPI:1528552395
Name:YOUNGBERG, HEATHER (PA)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:
Last Name:YOUNGBERG
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10201 CARNEGIE AVE # CA-60
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44106-2130
Mailing Address - Country:US
Mailing Address - Phone:216-442-3732
Mailing Address - Fax:
Practice Address - Street 1:9500 EUCLID AVE # CA-60
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44195-2130
Practice Address - Country:US
Practice Address - Phone:216-442-3732
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-15
Last Update Date:2023-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA363A00000X
SC3997363A00000X
OH50.007816RX363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant