Provider Demographics
NPI:1447471487
Name:FAN, YOUNG C (MD)
Entity type:Individual
Prefix:DR
First Name:YOUNG
Middle Name:C
Last Name:FAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:119 EAST MECHANIC STREET
Mailing Address - Street 2:
Mailing Address - City:TITUSVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:16354-2161
Mailing Address - Country:US
Mailing Address - Phone:814-827-4602
Mailing Address - Fax:814-827-6322
Practice Address - Street 1:119 EAST MECHANIC STREET
Practice Address - Street 2:
Practice Address - City:TITUSVILLE
Practice Address - State:PA
Practice Address - Zip Code:16354-2161
Practice Address - Country:US
Practice Address - Phone:814-827-4602
Practice Address - Fax:814-827-6322
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD033879L174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0006010740001Medicaid
PA032140OtherPENNSYLVANIA BLUE SHIELD
PA0006010740001Medicaid
PAB33821Medicare UPIN