Basic Information
| Provider Information | |||||||||
| NPI: | 1629310347 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | YOUNG | ||||||||
| FirstName: | LAURA | ||||||||
| MiddleName: | DANIELLE | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1593 E POLSTON AVE | ||||||||
| Address2: | |||||||||
| City: | POST FALLS | ||||||||
| State: | ID | ||||||||
| PostalCode: | 838545326 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2082622300 | ||||||||
| FaxNumber: | 2082622390 | ||||||||
| Practice Location | |||||||||
| Address1: | 1551 E MULLAN AVE BLDG A STE 200A | ||||||||
| Address2: | |||||||||
| City: | POST FALLS | ||||||||
| State: | ID | ||||||||
| PostalCode: | 838545275 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2082622482 | ||||||||
| FaxNumber: | 2082627460 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/20/2013 | ||||||||
| LastUpdateDate: | 08/04/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/04/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207VF0040X | M-14875 | ID | N | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Female Pelvic Medicine and Reconstructive Surgery | 207VG0400X | M-14875 | ID | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 2140750 | 05 | WA | MEDICAID | 1629310347 | 05 | ID | MEDICAID |