Provider Demographics
NPI:1770332918
Name:YOUNG, PATREIS DESTANIE (PA)
Entity type:Individual
Prefix:MS
First Name:PATREIS
Middle Name:DESTANIE
Last Name:YOUNG
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 S PARK ST
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53715-1375
Mailing Address - Country:US
Mailing Address - Phone:608-287-2450
Mailing Address - Fax:
Practice Address - Street 1:1 S PARK ST
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53715-1375
Practice Address - Country:US
Practice Address - Phone:608-287-2450
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-17
Last Update Date:2024-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
WI8029363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant