Provider Demographics
NPI:1982133542
Name:LISA A YOUNG DO PLLC
Entity Type:Organization
Organization Name:LISA A YOUNG DO PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DO, OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:YOUNG
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:970-371-4260
Mailing Address - Street 1:2960 S BRIARWOOD LN
Mailing Address - Street 2:
Mailing Address - City:PINETOP
Mailing Address - State:AZ
Mailing Address - Zip Code:85935-7379
Mailing Address - Country:US
Mailing Address - Phone:970-371-4260
Mailing Address - Fax:
Practice Address - Street 1:2200 E SHOW LOW LAKE RD
Practice Address - Street 2:
Practice Address - City:SHOW LOW
Practice Address - State:AZ
Practice Address - Zip Code:85901-7831
Practice Address - Country:US
Practice Address - Phone:928-537-4375
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-06-07
Last Update Date:2017-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ006224207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ853249Medicaid