Provider Demographics
NPI:1578546743
Name:YOUNG, ANGELA T (PA-C)
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:T
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 1:1100 22ND ST SE
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97302-6558
Mailing Address - Country:US
Mailing Address - Phone:503-967-6771
Mailing Address - Fax:503-385-8421
Practice Address - Street 1:1100 22ND ST SE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97302-6558
Practice Address - Country:US
Practice Address - Phone:503-967-6771
Practice Address - Fax:503-385-8421
Is Sole Proprietor?:No
Enumeration Date:2005-11-22
Last Update Date:2022-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPA00393363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORR85421Medicare UPIN
OR106712Medicare PIN