Provider Demographics
NPI:1912218355
Name:YOUNG, TAMARA LYNN (ATC, OTC, MED)
Entity Type:Individual
Prefix:
First Name:TAMARA
Middle Name:LYNN
Last Name:YOUNG
Suffix:
Gender:F
Credentials:ATC, OTC, MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1100 VIRGINIA AVE
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65212-0001
Mailing Address - Country:US
Mailing Address - Phone:573-884-4767
Mailing Address - Fax:573-884-9063
Practice Address - Street 1:1100 VIRGINIA AVE
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65212-0001
Practice Address - Country:US
Practice Address - Phone:573-884-4767
Practice Address - Fax:573-884-9063
Is Sole Proprietor?:No
Enumeration Date:2010-06-30
Last Update Date:2010-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20001509082255A2300X
246ZS0410X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No246ZS0410XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Technologist