Basic Information
| Provider Information | |||||||||
| NPI: | 1063969863 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | YOUNG | ||||||||
| FirstName: | WESLEY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 27005 76TH AVE | ||||||||
| Address2: | |||||||||
| City: | NEW HYDE PARK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 110401402 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7184707000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2139 AUBURN AVE | ||||||||
| Address2: | |||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452192989 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5135850436 | ||||||||
| FaxNumber: | 5135854099 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/08/2016 | ||||||||
| LastUpdateDate: | 08/14/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 23 020098 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 0305869 | 05 | OH | MEDICAID |