Healthcare Provider Details

I. General information

NPI: 1164457057
Provider Name (Legal Business Name): BRANDON MARK YOUNG PT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/11/2006
Last Update Date: 04/12/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2121 E WILLIAMS ST SUITE 108
APEX NC
27539-7764
US

IV. Provider business mailing address

2121 E WILLIAMS ST SUITE 108
APEX NC
27539-7764
US

V. Phone/Fax

Practice location:
  • Phone: 919-372-8412
  • Fax: 919-267-6556
Mailing address:
  • Phone: 919-946-7011
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number9857
License Number StateNC

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier079K8
Identifier TypeOTHER
Identifier StateNC
Identifier IssuerBCBS PROVIDER NUMBER

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: