Healthcare Provider Details

I. General information

NPI: 1114210960
Provider Name (Legal Business Name): SOFIA LUISA YOUNG PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/25/2011
Last Update Date: 07/03/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4311 E LOHMAN AVE
LAS CRUCES NM
88011-8255
US

IV. Provider business mailing address

4311 E LOHMAN AVE
LAS CRUCES NM
88011-8255
US

V. Phone/Fax

Practice location:
  • Phone: 575-556-6800
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA2011-0009
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: