Healthcare Provider Details

I. General information

NPI: 1457902108
Provider Name (Legal Business Name): CALEB SAMUEL YOUNG APNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/24/2019
Last Update Date: 04/22/2024
Certification Date: 04/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3023 S 84TH ST
MILWAUKEE WI
53227-3703
US

IV. Provider business mailing address

PO BOX 735044
CHICAGO IL
60673-5044
US

V. Phone/Fax

Practice location:
  • Phone: 414-329-4979
  • Fax: 414-328-4494
Mailing address:
  • Phone: 800-326-2250
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number9618
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number9618-33
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: