Healthcare Provider Details

I. General information

NPI: 1730755265
Provider Name (Legal Business Name): ROSA KIM YOUNG PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/03/2021
Last Update Date: 02/06/2023
Certification Date: 02/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1060 SW 4TH ST
MOORE OK
73160-2494
US

IV. Provider business mailing address

1060 SW 4TH ST
MOORE OK
73160-2494
US

V. Phone/Fax

Practice location:
  • Phone: 405-302-2661
  • Fax:
Mailing address:
  • Phone: 405-302-2661
  • Fax: 405-302-2670

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number4594
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: