=====================================================
General NPI Number Information
=====================================================
NPI Number | 1689797029
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | THOMAS P YOUNG III PHD, NP
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/09/2007
-----------------------------------------------------
Last Update Date | 01/24/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 830 2ND ST STE A
-----------------------------------------------------
City | SANTA ROSA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95404-4620
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 415-895-1441
-----------------------------------------------------
Fax | 415-895-1288
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 550 RICHMOND DR
-----------------------------------------------------
City | SANTA ROSA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95401-3618
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 415-301-0902
-----------------------------------------------------
Fax | 415-895-1288
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LA2200X
-----------------------------------------------------
Taxonomy Name | Adult Health Nurse Practitioner
-----------------------------------------------------
License Number | 7662
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363LA2200X
-----------------------------------------------------
Taxonomy Name | Adult Health Nurse Practitioner
-----------------------------------------------------
License Number | 349096
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------