Provider Demographics
NPI:1659556470
Name:YOUNG, STEPHEN KEITH (CRNA)
Entity Type:Individual
Prefix:MR
First Name:STEPHEN
Middle Name:KEITH
Last Name:YOUNG
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6010 REDCOAT LN
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75703-4537
Mailing Address - Country:US
Mailing Address - Phone:214-796-9828
Mailing Address - Fax:
Practice Address - Street 1:774 S BECKHAM AVE
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75701-1902
Practice Address - Country:US
Practice Address - Phone:903-531-4449
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-12-31
Last Update Date:2016-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX698498367500000X
TXAP118341367500000X
OR200860007CRNA367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX75-0818167OtherTRICARE
TXP01588716OtherRAIL ROAD MEDICARE
TX471584YQ8AMedicare PIN