Provider Demographics
NPI:1871599985
Name:YOUNGS, DIANA (ANPC)
Entity type:Individual
Prefix:
First Name:DIANA
Middle Name:
Last Name:YOUNGS
Suffix:
Gender:F
Credentials:ANPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1500 ROUTE 112 BLDG 4
Mailing Address - Street 2:
Mailing Address - City:PORT JEFFERSON STATION
Mailing Address - State:NY
Mailing Address - Zip Code:11776-8055
Mailing Address - Country:US
Mailing Address - Phone:631-751-3000
Mailing Address - Fax:631-509-6559
Practice Address - Street 1:1500 ROUTE 112 BLDG 4
Practice Address - Street 2:
Practice Address - City:PORT JEFFERSON STATION
Practice Address - State:NY
Practice Address - Zip Code:11776-8055
Practice Address - Country:US
Practice Address - Phone:631-751-3000
Practice Address - Fax:631-509-6654
Is Sole Proprietor?:No
Enumeration Date:2005-06-23
Last Update Date:2021-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF370030363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02597895Medicaid
NY0839G1Medicare PIN
NY02597895Medicaid