Provider Demographics
NPI:1689884298
Name:YOUNGBLOOD, ELTON (PA-C)
Entity Type:Individual
Prefix:
First Name:ELTON
Middle Name:
Last Name:YOUNGBLOOD
Suffix:
Gender:M
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:PO BOX 4046
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65808-4046
Mailing Address - Country:US
Mailing Address - Phone:417-269-7241
Mailing Address - Fax:417-269-7567
Practice Address - Street 1:525 BRANSON LANDING BLVD STE 100
Practice Address - Street 2:
Practice Address - City:BRANSON
Practice Address - State:MO
Practice Address - Zip Code:65616-2152
Practice Address - Country:US
Practice Address - Phone:417-348-7490
Practice Address - Fax:417-348-8881
Is Sole Proprietor?:No
Enumeration Date:2007-05-23
Last Update Date:2019-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2002003300363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant