Provider Demographics
NPI:1871589390
Name:YOUNG, PATTI MARIE (MD)
Entity type:Individual
Prefix:
First Name:PATTI MARIE
Middle Name:
Last Name:YOUNG
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:PATTI MARIE
Other - Middle Name:
Other - Last Name:FAZIO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:3610 MICHELLE WITMER MEMORIAL DR
Mailing Address - Street 2:SUITE 100
Mailing Address - City:NEW BERLIN
Mailing Address - State:WI
Mailing Address - Zip Code:53151-5292
Mailing Address - Country:US
Mailing Address - Phone:262-789-6020
Mailing Address - Fax:262-789-6025
Practice Address - Street 1:4855 S MOORLAND RD STE 250
Practice Address - Street 2:
Practice Address - City:NEW BERLIN
Practice Address - State:WI
Practice Address - Zip Code:53151-7494
Practice Address - Country:US
Practice Address - Phone:262-789-6020
Practice Address - Fax:262-789-6025
Is Sole Proprietor?:No
Enumeration Date:2005-09-20
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI37591208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI32407200Medicaid
WI32407200Medicaid
WI68735Medicare ID - Type Unspecified