MEDICARE: HAROLD WAYNE YOUNG II PMHNP-NP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	95019914	CA

General Provider Information

NPI Number	:	1417602046
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	HAROLD WAYNE YOUNG II PMHNP-NP

Provider Business Mailing Address
First Line	:	4074 1/2 TEXAS ST
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92104-6032
Country	:	US
Telephone Number	:	865-258-0161
Fax Number	:

Provider Business Practice Location Address
First Line	:	4074 1/2 TEXAS ST
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92104-6032
Country	:	US
Telephone Number	:	865-258-0161
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/11/2022
Last Update Date	:	02/11/2022

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