Healthcare Provider Details

I. General information

NPI: 1144619875
Provider Name (Legal Business Name): SHELLEY BRIGHT YOUNG PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/19/2015
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

818 SAINT SEBASTIAN WAY STE 104
AUGUSTA GA
30901-2652
US

IV. Provider business mailing address

PO BOX 1705
AUGUSTA GA
30903-1705
US

V. Phone/Fax

Practice location:
  • Phone: 706-434-0130
  • Fax: 706-434-0131
Mailing address:
  • Phone: 706-854-6917
  • Fax: 706-774-7230

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number007294
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: