Provider Demographics
NPI:1174653448
Name:CLOUD, COURTNEY KAY (PAC)
Entity Type:Individual
Prefix:
First Name:COURTNEY
Middle Name:KAY
Last Name:CLOUD
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5060 ADDISON CIR APT 3835
Mailing Address - Street 2:
Mailing Address - City:ADDISON
Mailing Address - State:TX
Mailing Address - Zip Code:75001-6686
Mailing Address - Country:US
Mailing Address - Phone:940-659-8286
Mailing Address - Fax:
Practice Address - Street 1:7515 GREENVILLE AVE
Practice Address - Street 2:SUITE 1030
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75231-3831
Practice Address - Country:US
Practice Address - Phone:214-691-2111
Practice Address - Fax:469-916-8713
Is Sole Proprietor?:No
Enumeration Date:2007-03-06
Last Update Date:2012-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA05170363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX217092004Medicaid
TX217092005Medicaid
TX217092003Medicaid
TXTXB114160Medicare PIN
TX217092003Medicaid