Provider Demographics
NPI:1972562726
Name:YOUNG, TRACY M (FNP)
Entity Type:Individual
Prefix:MRS
First Name:TRACY
Middle Name:M
Last Name:YOUNG
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:MS
Other - First Name:TRACY
Other - Middle Name:M
Other - Last Name:LANE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6259 W EMERALD ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83704-8731
Mailing Address - Country:US
Mailing Address - Phone:208-489-1900
Mailing Address - Fax:208-375-5286
Practice Address - Street 1:6259 W EMERALD ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-8731
Practice Address - Country:US
Practice Address - Phone:208-489-1900
Practice Address - Fax:208-375-5286
Is Sole Proprietor?:No
Enumeration Date:2006-03-21
Last Update Date:2008-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDNP480363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDP14471Medicare UPIN
ID1343076Medicare ID - Type Unspecified