Provider Demographics
NPI:1659521599
Name:YOUNG, RANDOLPH EDWARD (BSN, RN)
Entity Type:Individual
Prefix:MR
First Name:RANDOLPH
Middle Name:EDWARD
Last Name:YOUNG
Suffix:
Gender:M
Credentials:BSN, RN
Other - Prefix:MR
Other - First Name:RANDY
Other - Middle Name:EDWARD
Other - Last Name:YOUNG
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:BSN, RN
Mailing Address - Street 1:2075 ST. RAYMONDS AVENUE
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10462
Mailing Address - Country:US
Mailing Address - Phone:718-409-0268
Mailing Address - Fax:
Practice Address - Street 1:1500 PELHAM PKWY S
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10461-1100
Practice Address - Country:US
Practice Address - Phone:718-597-3400
Practice Address - Fax:718-597-6917
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-29
Last Update Date:2008-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY468489-1163WC1500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC1500XNursing Service ProvidersRegistered NurseCommunity Health