Basic Information
| Provider Information | |||||||||
| NPI: | 1194717603 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | YOUNG | ||||||||
| FirstName: | JOY | ||||||||
| MiddleName: | P | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PAC | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | WOODS | ||||||||
| OtherFirstName: | JOY | ||||||||
| OtherMiddleName: | P | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 1547 | ||||||||
| Address2: | |||||||||
| City: | CHARLESTON | ||||||||
| State: | WV | ||||||||
| PostalCode: | 253261547 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3044651378 | ||||||||
| FaxNumber: | 3044692981 | ||||||||
| Practice Location | |||||||||
| Address1: | 30 GRIZZLEY LN | ||||||||
| Address2: | NICHOLAS COUNTY SCHOOL BASED HEALTH CENTER | ||||||||
| City: | SUMMERSVILLE | ||||||||
| State: | WV | ||||||||
| PostalCode: | 266519736 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3048833900 | ||||||||
| FaxNumber: | 3048723190 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/19/2005 | ||||||||
| LastUpdateDate: | 03/16/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 1020 | WV | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 3810005937 | 05 | WV | MEDICAID |