Provider Demographics
NPI:1033742580
Name:COURTNEY, COLLEEN (PA-C)
Entity Type:Individual
Prefix:
First Name:COLLEEN
Middle Name:
Last Name:COURTNEY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:COLLEEN
Other - Middle Name:
Other - Last Name:MARSALA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:1723 CHERRY CT
Mailing Address - Street 2:
Mailing Address - City:LAKE VILLA
Mailing Address - State:IL
Mailing Address - Zip Code:60046-5774
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:12500 AURORA DR
Practice Address - Street 2:
Practice Address - City:PLEASANT PRAIRIE
Practice Address - State:WI
Practice Address - Zip Code:53158-1227
Practice Address - Country:US
Practice Address - Phone:262-857-5400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-12
Last Update Date:2024-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5156-023363A00000X
363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100103632Medicaid