Provider Demographics
NPI:1649618687
Name:YOUNG, MARY CATHERINE
Entity type:Individual
Prefix:DR
First Name:MARY
Middle Name:CATHERINE
Last Name:YOUNG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:CATHERINE
Other - Last Name:YOUNG
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:532 MERIDAN ST
Mailing Address - Street 2:
Mailing Address - City:MORGANTOWN
Mailing Address - State:WV
Mailing Address - Zip Code:26505-2318
Mailing Address - Country:US
Mailing Address - Phone:304-542-2512
Mailing Address - Fax:
Practice Address - Street 1:532 MERIDAN ST
Practice Address - Street 2:
Practice Address - City:MORGANTOWN
Practice Address - State:WV
Practice Address - Zip Code:26505
Practice Address - Country:US
Practice Address - Phone:304-542-2512
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-06-12
Last Update Date:2018-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV64086163W00000X
WVAPRN64086CRNA367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810026331Medicaid
WV9333201OtherGROUP MEDICARE PTAN - MID-ATLANTIC ANESTHESIA CONSULTANTS
WV3810026331Medicaid
WV3810026331Medicaid