Basic Information
| Provider Information | |||||||||
| NPI: | 1124589551 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | YOUNG | ||||||||
| FirstName: | EMILY | ||||||||
| MiddleName: | LOUISE | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6858 OLD DOMINION DR | ||||||||
| Address2: | |||||||||
| City: | MC LEAN | ||||||||
| State: | VA | ||||||||
| PostalCode: | 221013899 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7038479800 | ||||||||
| FaxNumber: | 7033567074 | ||||||||
| Practice Location | |||||||||
| Address1: | 6858 OLD DOMINION DR | ||||||||
| Address2: | |||||||||
| City: | MC LEAN | ||||||||
| State: | VA | ||||||||
| PostalCode: | 221013899 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7038479800 | ||||||||
| FaxNumber: | 7033567074 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/28/2019 | ||||||||
| LastUpdateDate: | 01/23/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 01/23/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 0110-006770 | VA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0110-006770 | 01 | VA | VA LICENSE PRACTICE AS A PA | OTHER |