Healthcare Provider Details

I. General information

NPI: 1609364033
Provider Name (Legal Business Name): ANDREW MARK KAVI YOUNG RN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/01/2018
Last Update Date: 07/30/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

65177 210TH ST
ELKTON MN
55933
US

IV. Provider business mailing address

65177 210TH ST
ELKTON MN
55933-8843
US

V. Phone/Fax

Practice location:
  • Phone: 612-590-1171
  • Fax:
Mailing address:
  • Phone: 612-590-1171
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WH0200X
TaxonomyHome Health Registered Nurse
License Number198851-6
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: