Basic Information
| Provider Information | |||||||||
| NPI: | 1326010232 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | YOUNG | ||||||||
| FirstName: | KATHLEEN | ||||||||
| MiddleName: | ELIZABETH | ||||||||
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| Credential: | MB BCH ( MD EQUIVALE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1363 W SPRUCE AVE | ||||||||
| Address2: | |||||||||
| City: | WASILLA | ||||||||
| State: | AK | ||||||||
| PostalCode: | 996545327 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9073762411 | ||||||||
| FaxNumber: | 9073523373 | ||||||||
| Practice Location | |||||||||
| Address1: | 1363 W SPRUCE AVE | ||||||||
| Address2: | |||||||||
| City: | WASILLA | ||||||||
| State: | AK | ||||||||
| PostalCode: | 996545327 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9073762411 | ||||||||
| FaxNumber: | 9073523373 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/03/2006 | ||||||||
| LastUpdateDate: | 05/06/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 4173 | AK | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | MD4173 | 05 | AK | MEDICAID |