Provider Demographics
NPI:1386772952
Name:YOUNG, KISHA ROCHELLE (MD)
Entity type:Individual
Prefix:DR
First Name:KISHA
Middle Name:ROCHELLE
Last Name:YOUNG
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:KISHA
Other - Middle Name:ROCHELLE
Other - Last Name:YOUNG
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
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:704-384-9920
Mailing Address - Fax:704-384-9925
Practice Address - Street 1:4105 MATTHEWS MINT HILL RD
Practice Address - Street 2:
Practice Address - City:MINT HILL
Practice Address - State:NC
Practice Address - Zip Code:28105-3633
Practice Address - Country:US
Practice Address - Phone:704-384-9920
Practice Address - Fax:704-384-9925
Is Sole Proprietor?:No
Enumeration Date:2007-03-02
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC134137207Q00000X
NC200701684207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5912253Medicaid
NC134137OtherMD LIMITED TRAINING LIC
NC134137OtherMD LIMITED TRAINING LIC
NC2073994Medicare UPIN