Provider Demographics
NPI:1194594036
Name:KRICKOVIC, GAELYN ELLIOTT YOUNG (PA)
Entity type:Individual
Prefix:MRS
First Name:GAELYN
Middle Name:ELLIOTT YOUNG
Last Name:KRICKOVIC
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Mailing Address - Street 1:PO BOX 60447
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-0447
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1730 KERNERSVILLE MEDICAL PKWY STE 104
Practice Address - Street 2:
Practice Address - City:KERNERSVILLE
Practice Address - State:NC
Practice Address - Zip Code:27284-7198
Practice Address - Country:US
Practice Address - Phone:336-765-5470
Practice Address - Fax:336-499-5428
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-20
Last Update Date:2024-08-22
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
363A00000X
NC5019933363LP0200X
NC0010-14225363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics