Provider Demographics
NPI:1750779039
Name:YOUNG, TRAVIS A (NP-C)
Entity type:Individual
Prefix:
First Name:TRAVIS
Middle Name:A
Last Name:YOUNG
Suffix:
Gender:M
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3008 E PARK AVE
Mailing Address - Street 2:
Mailing Address - City:BRUNSWICK
Mailing Address - State:GA
Mailing Address - Zip Code:31520-4241
Mailing Address - Country:US
Mailing Address - Phone:912-265-2142
Mailing Address - Fax:912-265-0530
Practice Address - Street 1:114 NORTHPARK DR
Practice Address - Street 2:
Practice Address - City:BRUNSWICK
Practice Address - State:GA
Practice Address - Zip Code:31520-2184
Practice Address - Country:US
Practice Address - Phone:912-268-4471
Practice Address - Fax:912-771-8053
Is Sole Proprietor?:No
Enumeration Date:2015-01-08
Last Update Date:2018-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2014039709363LF0000X
GARN274244363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
106070011Medicare PIN