Healthcare Provider Details

I. General information

NPI: 1558594267
Provider Name (Legal Business Name): PETER GEOFFREY YOUNG
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/27/2009
Last Update Date: 08/27/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

480 MANOR PLZ
PACIFICA CA
94044-1839
US

IV. Provider business mailing address

1816 LAKESHORE AVE
OAKLAND CA
94606-1222
US

V. Phone/Fax

Practice location:
  • Phone: 650-591-1718
  • Fax:
Mailing address:
  • Phone: 510-735-6196
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: