Basic Information
| Provider Information | |||||||||
| NPI: | 1629110390 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | YOUNG | ||||||||
| FirstName: | BRADLEY | ||||||||
| MiddleName: | JAMES | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4760 W SUNSET BLVD | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900276063 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8009548000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4760 W SUNSET BLVD | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900276063 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3237834878 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/12/2007 | ||||||||
| LastUpdateDate: | 11/30/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AS0400X | PA 14403 | CA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical |
ID Information
| ID | Type | State | Issuer | Description | 1035657 | 01 | CA | NCCPA CERTIFICATE # | OTHER | PA 14403 | 01 | CA | PAEC LICENSE NUMBER | OTHER | MY1069601 | 01 | CA | DEA REGISTRATION # | OTHER |