Healthcare Provider Details

I. General information

NPI: 1447471487
Provider Name (Legal Business Name): YOUNG C. FAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/01/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

119 EAST MECHANIC STREET
TITUSVILLE PA
16354-2161
US

IV. Provider business mailing address

119 EAST MECHANIC STREET
TITUSVILLE PA
16354-2161
US

V. Phone/Fax

Practice location:
  • Phone: 814-827-4602
  • Fax: 814-827-6322
Mailing address:
  • Phone: 814-827-4602
  • Fax: 814-827-6322

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberMD033879L
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: