MEDICARE: MARK YOUNGBERG MS-IV

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	390200000X	Student in an Organized Health Care Education/Training Program

General Provider Information

NPI Number	:	1033408141
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARK YOUNGBERG MS-IV

Provider Business Mailing Address
First Line	:	1959 NE PACIFIC ST
Second Line	:	BOX 356540, BB-1440 HSB
City	:	SEATTLE
State	:	WA
Zip	:	98195-6540
Country	:	US
Telephone Number	:	206-543-2773
Fax Number	:	206-543-2958

Provider Business Practice Location Address
First Line	:	1959 NE PACIFIC ST
Second Line	:	BOX 356540, BB-1440 HSB
City	:	SEATTLE
State	:	WA
Zip	:	98195-6540
Country	:	US
Telephone Number	:	206-543-2773
Fax Number	:	206-543-2958

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/30/2011
Last Update Date	:	03/30/2011

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