Provider Demographics
NPI:1760912117
Name:YOUNG, NICOLE KALEEN (PA-C)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:KALEEN
Last Name:YOUNG
Suffix:
Gender:F
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 1:199 POLARIS CT
Mailing Address - Street 2:
Mailing Address - City:VALLEJO
Mailing Address - State:CA
Mailing Address - Zip Code:94591-6943
Mailing Address - Country:US
Mailing Address - Phone:707-334-2615
Mailing Address - Fax:
Practice Address - Street 1:100 HOSPITAL DR STE 303
Practice Address - Street 2:
Practice Address - City:VALLEJO
Practice Address - State:CA
Practice Address - Zip Code:94589-2583
Practice Address - Country:US
Practice Address - Phone:707-645-7210
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-19
Last Update Date:2019-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA54665363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant