Healthcare Provider Details

I. General information

NPI: 1336826692
Provider Name (Legal Business Name): BRADLEY KEVIN YOUNG FNP-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/29/2023
Last Update Date: 07/18/2023
Certification Date: 07/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2041 FISHER ARCH SUITE 140
VIRGINIA BEACH VA
23456
US

IV. Provider business mailing address

8756 S 1700 E
SANDY UT
84093-1408
US

V. Phone/Fax

Practice location:
  • Phone: 757-301-6985
  • Fax:
Mailing address:
  • Phone: 208-380-0763
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number11388965-4405
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: