Provider Demographics
NPI:1669492864
Name:YOUNG, TINA M (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:MRS
First Name:TINA
Middle Name:M
Last Name:YOUNG
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:282C FREEMAN ROAD
Mailing Address - Street 2:
Mailing Address - City:MUNNSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:13409
Mailing Address - Country:US
Mailing Address - Phone:315-495-6226
Mailing Address - Fax:
Practice Address - Street 1:138 NORTH COURT STREET
Practice Address - Street 2:
Practice Address - City:WAMPSVILLE
Practice Address - State:NY
Practice Address - Zip Code:13163
Practice Address - Country:US
Practice Address - Phone:315-366-2327
Practice Address - Fax:315-366-2599
Is Sole Proprietor?:No
Enumeration Date:2006-07-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF300094-1363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00569860Medicaid
NY00569860Medicaid