Healthcare Provider Details

I. General information

NPI: 1265407811
Provider Name (Legal Business Name): RUSSELL E YOUNG PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/17/2006
Last Update Date: 07/15/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 JACOB LN
ANOKA MN
55303
US

IV. Provider business mailing address

8100 34TH AVE S 21110Q
BLOOMINGTON MN
55425-1672
US

V. Phone/Fax

Practice location:
  • Phone: 763-587-4400
  • Fax: 763-587-4205
Mailing address:
  • Phone: 952-883-5790
  • Fax: 952-883-5395

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number8927
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: