Provider Demographics
NPI:1689785156
Name:YOUNG, PHYLLIS (PA)
Entity Type:Individual
Prefix:
First Name:PHYLLIS
Middle Name:
Last Name:YOUNG
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 1:8 RUE DE VIN DR
Mailing Address - Street 2:
Mailing Address - City:MARLBORO
Mailing Address - State:NY
Mailing Address - Zip Code:12542-5953
Mailing Address - Country:US
Mailing Address - Phone:845-913-7737
Mailing Address - Fax:877-291-6044
Practice Address - Street 1:254 ROUTE 17K
Practice Address - Street 2:SUITE 203
Practice Address - City:NEWBURGH
Practice Address - State:NY
Practice Address - Zip Code:12550-8343
Practice Address - Country:US
Practice Address - Phone:845-913-7737
Practice Address - Fax:877-291-6044
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2017-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY003633363AM0700X
CT002105363AM0700X
NJ25MP00335300363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
S62731Medicare UPIN