Provider Demographics
NPI:1649885443
Name:YOUNG, TABITHA RENA (APRN)
Entity type:Individual
Prefix:
First Name:TABITHA
Middle Name:RENA
Last Name:YOUNG
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:107 E DORA LN
Mailing Address - Street 2:
Mailing Address - City:POTEAU
Mailing Address - State:OK
Mailing Address - Zip Code:74953-5518
Mailing Address - Country:US
Mailing Address - Phone:918-839-9699
Mailing Address - Fax:
Practice Address - Street 1:1011 N BROADWAY ST
Practice Address - Street 2:
Practice Address - City:POTEAU
Practice Address - State:OK
Practice Address - Zip Code:74953-2609
Practice Address - Country:US
Practice Address - Phone:918-839-9699
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-09
Last Update Date:2020-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK200071207Q00000X
OK72781207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine