Provider Demographics
NPI:1255345153
Name:YOUNG, KATHRYN A (MD)
Entity type:Individual
Prefix:MS
First Name:KATHRYN
Middle Name:A
Last Name:YOUNG
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2500 N STATE ST
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39216-4500
Mailing Address - Country:US
Mailing Address - Phone:601-815-8173
Mailing Address - Fax:601-815-8189
Practice Address - Street 1:2500 N STATE ST
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-4500
Practice Address - Country:US
Practice Address - Phone:601-815-8173
Practice Address - Fax:601-815-8189
Is Sole Proprietor?:No
Enumeration Date:2006-07-28
Last Update Date:2012-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI478652080P0203X
MN537662080P0203X
MS213542080P0203X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0203XAllopathic & Osteopathic PhysiciansPediatricsPediatric Critical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI34624300Medicaid
I30110Medicare UPIN
WI34624300Medicaid
MS302I378626Medicare PIN
WI082R 73-601Medicare ID - Type UnspecifiedMILWAUKEE COUNTY