Healthcare Provider Details

I. General information

NPI: 1871044826
Provider Name (Legal Business Name): KALA YOUNG PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/14/2016
Last Update Date: 09/24/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

385 W WESMARK BLVD
SUMTER SC
29150-1987
US

IV. Provider business mailing address

2537 SIENA WAY
VALRICO FL
33596-8309
US

V. Phone/Fax

Practice location:
  • Phone: 803-773-5227
  • Fax: 803-746-7445
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA3038
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: