1215539721 NPI number — STEPHANIE LYNN COURTS PA-C

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1215539721 NPI number — STEPHANIE LYNN COURTS PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
COURTS
Provider First Name:
STEPHANIE
Provider Middle Name:
LYNN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA-C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1215539721
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/07/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1112
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FAIRMONT
Provider Business Mailing Address State Name:
WV
Provider Business Mailing Address Postal Code:
26555-1112
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
304-366-0700
Provider Business Mailing Address Fax Number:
304-367-8766

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
118 MARKET ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MANNINGTON
Provider Business Practice Location Address State Name:
WV
Provider Business Practice Location Address Postal Code:
26582-1131
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
304-986-1750
Provider Business Practice Location Address Fax Number:
304-986-3742
Provider Enumeration Date:
11/10/2020

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363A00000X , with the licence number:  2525 , registered in the state of WV ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 390200000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1215539721 , issued by the state of ( WV ) . This identifiers is of the category "MEDICAID".




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