Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 152W00000X | Optometrist | 18004269A | IN |
NPI | 1003498296 |
---|---|
Provider Name | Connor David Young |
First Address | Vienna, VA 22182-3970 |
Second Address | Indianapolis, IN 46220-1961 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 27/04/2021 |
Last Update Date | 18/06/2021 |