Provider Demographics
NPI:1477430783
Name:YOUNG, TYSON M
Entity type:Individual
Prefix:
First Name:TYSON
Middle Name:M
Last Name:YOUNG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7813 E HIGHWAY 90
Mailing Address - Street 2:
Mailing Address - City:JEANERETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70544-6531
Mailing Address - Country:US
Mailing Address - Phone:337-412-8023
Mailing Address - Fax:
Practice Address - Street 1:7813 E HIGHWAY 90
Practice Address - Street 2:
Practice Address - City:JEANERETTE
Practice Address - State:LA
Practice Address - Zip Code:70544-6531
Practice Address - Country:US
Practice Address - Phone:337-412-8023
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-08-19
Last Update Date:2025-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA1947133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered