Provider Demographics
NPI:1740317510
Name:YOUNG, TAMARA K (CNM)
Entity type:Individual
Prefix:
First Name:TAMARA
Middle Name:K
Last Name:YOUNG
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:TAMARA
Other - Middle Name:
Other - Last Name:YEKYAR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:621 S NEW BALLAS RD STE 2009B
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141-8265
Mailing Address - Country:US
Mailing Address - Phone:314-251-7498
Mailing Address - Fax:
Practice Address - Street 1:615 S NEW BALLAS RD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141-8221
Practice Address - Country:US
Practice Address - Phone:314-251-6092
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-27
Last Update Date:2025-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209028382363LF0000X, 363LP0808X, 367A00000X
MO2018032033367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILK15025Medicare UPIN
IL208685Medicare ID - Type UnspecifiedGROUP #