Provider Demographics
NPI:1922362797
Name:YOUNG, NICOLE J (PA-C)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:J
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 1:3341 BEALE AVE
Mailing Address - Street 2:
Mailing Address - City:ALTOONA
Mailing Address - State:PA
Mailing Address - Zip Code:16601-1549
Mailing Address - Country:US
Mailing Address - Phone:814-944-5357
Mailing Address - Fax:814-946-8017
Practice Address - Street 1:3341 BEALE AVE
Practice Address - Street 2:
Practice Address - City:ALTOONA
Practice Address - State:PA
Practice Address - Zip Code:16601-1549
Practice Address - Country:US
Practice Address - Phone:814-944-5357
Practice Address - Fax:814-946-8017
Is Sole Proprietor?:No
Enumeration Date:2012-06-27
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PATMA052664363AM0700X, 363AS0400X
PAMA055624363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PATMA052664OtherTEMPORARY STATE LICENSE
PAMA055624OtherPA STATE LICENSE