Provider Demographics
NPI:1184212441
Name:WHITE, KOURTNEY ELIZABETH (PA)
Entity Type:Individual
Prefix:
First Name:KOURTNEY
Middle Name:ELIZABETH
Last Name:WHITE
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 1:700 E CENTER ST
Mailing Address - Street 2:
Mailing Address - City:DOUGLAS
Mailing Address - State:WY
Mailing Address - Zip Code:82633-2446
Mailing Address - Country:US
Mailing Address - Phone:307-358-7359
Mailing Address - Fax:
Practice Address - Street 1:700 E CENTER ST
Practice Address - Street 2:
Practice Address - City:DOUGLAS
Practice Address - State:WY
Practice Address - Zip Code:82633-2446
Practice Address - Country:US
Practice Address - Phone:307-358-7359
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-04
Last Update Date:2021-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYPT912363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical