Healthcare Provider Details

I. General information

NPI: 1336826692
Provider Name (Legal Business Name): BRADLEY KEVIN YOUNG FNP-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/29/2023
Last Update Date: 08/04/2026
Certification Date: 08/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

784 S CLEARWATER LOOP
POST FALLS ID
83854-9599
US

IV. Provider business mailing address

283 N 400 W
BLACKFOOT ID
83221-5471
US

V. Phone/Fax

Practice location:
  • Phone: 208-495-6400
  • Fax: 800-396-5232
Mailing address:
  • Phone: 208-380-0763
  • Fax: 800-396-5232

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number6171448
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: