Healthcare Provider Details

I. General information

NPI: 1912218355
Provider Name (Legal Business Name): TAMARA LYNN YOUNG ATC, OTC, M.ED
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/30/2010
Last Update Date: 08/25/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 VIRGINIA AVE
COLUMBIA MO
65212-0001
US

IV. Provider business mailing address

1100 VIRGINIA AVE
COLUMBIA MO
65212-0001
US

V. Phone/Fax

Practice location:
  • Phone: 573-884-4767
  • Fax: 573-884-9063
Mailing address:
  • Phone: 573-884-4767
  • Fax: 573-884-9063

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number2000150908
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code246ZS0410X
TaxonomySurgical Technologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: