Provider Demographics
NPI:1609596758
Name:DEYOUNG, CLEMMIE JO (PA-C)
Entity type:Individual
Prefix:
First Name:CLEMMIE
Middle Name:JO
Last Name:DEYOUNG
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:CLEMMIE
Other - Middle Name:JO
Other - Last Name:TAETS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:PO BOX 844658
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-4658
Mailing Address - Country:US
Mailing Address - Phone:800-994-0371
Mailing Address - Fax:254-215-9722
Practice Address - Street 1:2401 S 31ST ST
Practice Address - Street 2:
Practice Address - City:TEMPLE
Practice Address - State:TX
Practice Address - Zip Code:76508-1959
Practice Address - Country:US
Practice Address - Phone:254-724-2111
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-30
Last Update Date:2024-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical