Provider Demographics
NPI:1679536346
Name:COURTNEY, ANGELA L (PA)
Entity type:Individual
Prefix:
First Name:ANGELA
Middle Name:L
Last Name:COURTNEY
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:ANGI
Other - Middle Name:L
Other - Last Name:COURTNEY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PA
Mailing Address - Street 1:PO BOX 845347
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-5347
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5323 HARRY HINES BLVD
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75390-9257
Practice Address - Country:US
Practice Address - Phone:214-645-8995
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-11
Last Update Date:2020-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085001797363A00000X
TXPA01747363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
S52876Medicare UPIN