Healthcare Provider Details

I. General information

NPI: 1417446352
Provider Name (Legal Business Name): BRADLEY P YOUNG APRN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/07/2018
Last Update Date: 08/18/2020
Certification Date: 08/18/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11155 TUCKER RD
PLEASANTON KS
66075-8401
US

IV. Provider business mailing address

3011 N MICHIGAN ST
PITTSBURG KS
66762-2546
US

V. Phone/Fax

Practice location:
  • Phone: 913-352-8379
  • Fax: 913-352-8998
Mailing address:
  • Phone: 620-231-9873
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number136260
License Number StateOK
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number78117
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: