Provider Demographics
NPI:1750418877
Name:YOUNG, LARRY (CRNA)
Entity type:Individual
Prefix:
First Name:LARRY
Middle Name:
Last Name:YOUNG
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1360 MEDICAL PARK DR
Mailing Address - Street 2:
Mailing Address - City:MAYSVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:41056-9621
Mailing Address - Country:US
Mailing Address - Phone:606-759-5341
Mailing Address - Fax:606-759-7393
Practice Address - Street 1:1360 MEDICAL PARK DR
Practice Address - Street 2:
Practice Address - City:MAYSVILLE
Practice Address - State:KY
Practice Address - Zip Code:41056-9621
Practice Address - Country:US
Practice Address - Phone:606-759-5341
Practice Address - Fax:606-759-7393
Is Sole Proprietor?:No
Enumeration Date:2007-02-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1034014367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7432874100Medicaid
KY74900440Medicaid
KY611201265Medicare UPIN
KY7432874100Medicaid