Provider Demographics
NPI:1265407811
Name:YOUNG, RUSSELL E (PA)
Entity type:Individual
Prefix:
First Name:RUSSELL
Middle Name:E
Last Name:YOUNG
Suffix:
Gender:M
Credentials:PA
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Mailing Address - Street 1:8100 34TH AVE S
Mailing Address - Street 2:21110Q
Mailing Address - City:BLOOMINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:55425-1672
Mailing Address - Country:US
Mailing Address - Phone:952-883-5790
Mailing Address - Fax:952-883-5395
Practice Address - Street 1:601 JACOB LN
Practice Address - Street 2:
Practice Address - City:ANOKA
Practice Address - State:MN
Practice Address - Zip Code:55303
Practice Address - Country:US
Practice Address - Phone:763-587-4400
Practice Address - Fax:763-587-4205
Is Sole Proprietor?:No
Enumeration Date:2006-02-17
Last Update Date:2019-07-15
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Provider Licenses
StateLicense IDTaxonomies
MN363A00000X
MN8927363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
P24482Medicare UPIN