Provider Demographics
NPI:1588160121
Name:YOUNG, MICHELLE A (PA-C)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:A
Last Name:YOUNG
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 SIGMA DR STE 100
Mailing Address - Street 2:
Mailing Address - City:SUMMERVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29486-7722
Mailing Address - Country:US
Mailing Address - Phone:803-943-3813
Mailing Address - Fax:803-943-5971
Practice Address - Street 1:300 MAPLE ST W
Practice Address - Street 2:
Practice Address - City:HAMPTON
Practice Address - State:SC
Practice Address - Zip Code:29924
Practice Address - Country:US
Practice Address - Phone:803-943-3813
Practice Address - Fax:803-943-5971
Is Sole Proprietor?:No
Enumeration Date:2018-04-03
Last Update Date:2018-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC2879363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC3610PAMedicaid