Provider Demographics
NPI:1982911558
Name:YOUNG, TIMESHA J (PA-C)
Entity Type:Individual
Prefix:
First Name:TIMESHA
Middle Name:J
Last Name:YOUNG
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:TIMESHA
Other - Middle Name:J
Other - Last Name:WIMS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:41000 WOODWARD AVE
Mailing Address - Street 2:STE 100 EAST
Mailing Address - City:BLOOMFIELD HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48304-5130
Mailing Address - Country:US
Mailing Address - Phone:248-593-6990
Mailing Address - Fax:248-593-5925
Practice Address - Street 1:41000 WOODWARD AVE
Practice Address - Street 2:STE 100 EAST
Practice Address - City:BLOOMFIELD HILLS
Practice Address - State:MI
Practice Address - Zip Code:48304-5130
Practice Address - Country:US
Practice Address - Phone:248-593-6990
Practice Address - Fax:248-593-5130
Is Sole Proprietor?:No
Enumeration Date:2010-09-02
Last Update Date:2023-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ4682363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ1093186OtherNCCPA
AZMD2251952OtherDEA