Provider Demographics
NPI:1699860510
Name:YOUNG, STEPHANIE A (PAC)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:A
Last Name:YOUNG
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5350 FRANTZ RD
Mailing Address - Street 2:
Mailing Address - City:DUBLIN
Mailing Address - State:OH
Mailing Address - Zip Code:43016-4259
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:165 REYNOLDS AVE STE A
Practice Address - Street 2:
Practice Address - City:BELLEFONTAINE
Practice Address - State:OH
Practice Address - Zip Code:43311-3005
Practice Address - Country:US
Practice Address - Phone:937-441-5204
Practice Address - Fax:937-592-0047
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2025-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X, 363AM0700X
OH50001814363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
YOPA28061Medicare PIN
P68470Medicare UPIN