Provider Demographics
NPI:1730139015
Name:YOUNG, ROBERT R (PA)
Entity type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:R
Last Name:YOUNG
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:12605 OOLA CT
Mailing Address - Street 2:
Mailing Address - City:CHOCTAW
Mailing Address - State:OK
Mailing Address - Zip Code:73020-2039
Mailing Address - Country:US
Mailing Address - Phone:719-440-0037
Mailing Address - Fax:
Practice Address - Street 1:12 E MACARTHUR ST
Practice Address - Street 2:
Practice Address - City:SHAWNEE
Practice Address - State:OK
Practice Address - Zip Code:74804-2135
Practice Address - Country:US
Practice Address - Phone:405-275-1001
Practice Address - Fax:405-275-1201
Is Sole Proprietor?:No
Enumeration Date:2006-05-10
Last Update Date:2025-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1245363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO52486265Medicaid
CO970014182OtherRR MEDICARE
COCOA103395Medicare PIN
CO52486265Medicaid
COCX0538Medicare PIN