Provider Demographics
NPI:1396997920
Name:YOUNG, ROBERT (CST/SFA)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:
Last Name:YOUNG
Suffix:
Gender:M
Credentials:CST/SFA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:104 GREENTREE DR
Mailing Address - Street 2:
Mailing Address - City:TAHLEQUAH
Mailing Address - State:OK
Mailing Address - Zip Code:74464-4113
Mailing Address - Country:US
Mailing Address - Phone:918-231-6827
Mailing Address - Fax:918-207-0006
Practice Address - Street 1:104 GREENTREE DR
Practice Address - Street 2:
Practice Address - City:TAHLEQUAH
Practice Address - State:OK
Practice Address - Zip Code:74464-4113
Practice Address - Country:US
Practice Address - Phone:918-231-6827
Practice Address - Fax:918-207-0006
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-14
Last Update Date:2008-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK246ZS0410X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZS0410XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Technologist