Basic Information
| Provider Information | |||||||||
| NPI: | 1982133542 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LISA A YOUNG DO PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2960 S BRIARWOOD LN | ||||||||
| Address2: | |||||||||
| City: | PINETOP | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 859357379 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9703714260 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2200 E SHOW LOW LAKE RD | ||||||||
| Address2: | |||||||||
| City: | SHOW LOW | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 859017831 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9285374375 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/07/2017 | ||||||||
| LastUpdateDate: | 06/08/2017 | ||||||||
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| AuthorizedOfficialLastName: | YOUNG | ||||||||
| AuthorizedOfficialFirstName: | LISA | ||||||||
| AuthorizedOfficialMiddleName: | ANN | ||||||||
| AuthorizedOfficialTitleorPosition: | DO, OWNER | ||||||||
| AuthorizedOfficialTelephone: | 9703714260 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | DO | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 006224 | AZ | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 853249 | 05 | AZ | MEDICAID |