Provider Demographics
NPI:1760933519
Name:YOUNG, GREGORY SR
Entity Type:Individual
Prefix:MR
First Name:GREGORY
Middle Name:
Last Name:YOUNG
Suffix:SR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1710 LAMAR AVE
Mailing Address - Street 2:
Mailing Address - City:WAYCROSS
Mailing Address - State:GA
Mailing Address - Zip Code:31503-5852
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1710 LAMAR AVE
Practice Address - Street 2:
Practice Address - City:WAYCROSS
Practice Address - State:GA
Practice Address - Zip Code:31503-5852
Practice Address - Country:US
Practice Address - Phone:912-816-5867
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-17
Last Update Date:2016-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor