Provider Demographics
NPI:1043489206
Name:ELLIOTT, COURTNEY (PA)
Entity Type:Individual
Prefix:
First Name:COURTNEY
Middle Name:
Last Name:ELLIOTT
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9915 PARK CEDAR DR
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28210-8905
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1000 BLYTHE BLVD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28203-5812
Practice Address - Country:US
Practice Address - Phone:704-355-2171
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-02-21
Last Update Date:2020-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-01207363A00000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC0641PAMedicaid
NC1043489206Medicaid
NC0010-01207OtherSTATE LICENSE
NCNCR357CMedicare PIN
NCNCR357EMedicare PIN
SC0641PAMedicaid
NCNCR357DMedicare PIN
NCNCR357BMedicare PIN
NCNCR357AMedicare PIN