Healthcare Provider Details

I. General information

NPI: 1487233805
Provider Name (Legal Business Name): CASEY LEE YOUNG
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/04/2021
Last Update Date: 08/30/2024
Certification Date: 08/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3801 UNIVERSITY DR
FAIRFAX VA
22030-2503
US

IV. Provider business mailing address

8910 JACKSON AVE
MANASSAS VA
20110-4958
US

V. Phone/Fax

Practice location:
  • Phone: 703-383-8130
  • Fax:
Mailing address:
  • Phone: 703-853-5416
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207YP0228X
TaxonomyPediatric Otolaryngology Physician
License Number0110009393
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: