Provider Demographics
NPI:1932297595
Name:YOUNG-PEN, TONI ELIZABETH (PAC)
Entity Type:Individual
Prefix:
First Name:TONI
Middle Name:ELIZABETH
Last Name:YOUNG-PEN
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3329 NUTMEG ST
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92104-5250
Mailing Address - Country:US
Mailing Address - Phone:619-807-2524
Mailing Address - Fax:
Practice Address - Street 1:4290 POLK AVE
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92105-1524
Practice Address - Country:US
Practice Address - Phone:619-563-0507
Practice Address - Fax:619-563-0015
Is Sole Proprietor?:No
Enumeration Date:2006-10-10
Last Update Date:2022-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA 18746363A00000X
WAPA10003685363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA149986OtherWORKERS COMPENSATION
WA8939200OtherCRIME VICTIMS
WA8413932Medicaid