Provider Demographics
NPI:1336782614
Name:YOUNG, DONOVAN
Entity type:Individual
Prefix:
First Name:DONOVAN
Middle Name:
Last Name:YOUNG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:307 COVE RD
Mailing Address - Street 2:
Mailing Address - City:RIVA
Mailing Address - State:MD
Mailing Address - Zip Code:21140-1225
Mailing Address - Country:US
Mailing Address - Phone:410-490-2755
Mailing Address - Fax:
Practice Address - Street 1:15459 ANNAPOLIS RD
Practice Address - Street 2:
Practice Address - City:BOWIE
Practice Address - State:MD
Practice Address - Zip Code:20715-1847
Practice Address - Country:US
Practice Address - Phone:240-544-0676
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-19
Last Update Date:2025-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
CA62441363A00000X
MDC0007680363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant