Basic Information
| Provider Information | |||||||||
| NPI: | 1326085309 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | YOUNG | ||||||||
| FirstName: | JEFFREY | ||||||||
| MiddleName: | ALAN | ||||||||
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| Credential: | PAC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 48788 DELMONT DR | ||||||||
| Address2: | |||||||||
| City: | NOVI | ||||||||
| State: | MI | ||||||||
| PostalCode: | 483742767 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2483471799 | ||||||||
| FaxNumber: | 8107658169 | ||||||||
| Practice Location | |||||||||
| Address1: | 6071 W OUTER DR | ||||||||
| Address2: | |||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482352624 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3139663300 | ||||||||
| FaxNumber: | 8107658169 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/31/2006 | ||||||||
| LastUpdateDate: | 08/30/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363AM0700X | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 363AS0400X | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical |
ID Information
| ID | Type | State | Issuer | Description | 1067781 | 01 | MI | NCCPA CERTIFICATE NUMBER | OTHER |