Basic Information
| Provider Information | |||||||||
| NPI: | 1043446222 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | YOUNG | ||||||||
| FirstName: | LISA | ||||||||
| MiddleName: | ANN | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 860 | ||||||||
| Address2: | WHITERIVER IHS | ||||||||
| City: | WHITERIVER | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 85941 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9283384911 | ||||||||
| FaxNumber: | 9283385508 | ||||||||
| Practice Location | |||||||||
| Address1: | 1 MAGNOLIA CT | ||||||||
| Address2: | |||||||||
| City: | MOULTRIE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 317686764 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2295029769 | ||||||||
| FaxNumber: | 9283385508 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/02/2009 | ||||||||
| LastUpdateDate: | 10/05/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/19/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 88683 | GA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.