Provider Demographics
NPI:1194460709
Name:KINHOLT, COURTNEY TRICIA (PA-C)
Entity Type:Individual
Prefix:MISS
First Name:COURTNEY
Middle Name:TRICIA
Last Name:KINHOLT
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:950 N DUESENBERG DR APT 11301
Mailing Address - Street 2:
Mailing Address - City:ONTARIO
Mailing Address - State:CA
Mailing Address - Zip Code:91764-5952
Mailing Address - Country:US
Mailing Address - Phone:406-945-1085
Mailing Address - Fax:
Practice Address - Street 1:950 N DUESENBERG DR APT 11301
Practice Address - Street 2:
Practice Address - City:ONTARIO
Practice Address - State:CA
Practice Address - Zip Code:91764-5952
Practice Address - Country:US
Practice Address - Phone:406-945-1085
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-28
Last Update Date:2022-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA40000059957500Medicaid