Provider Demographics
NPI:1235268293
Name:HABETZ, COURTNEY VICE (PA-C)
Entity Type:Individual
Prefix:MS
First Name:COURTNEY
Middle Name:VICE
Last Name:HABETZ
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:401 YOUNGSVILLE HWY
Mailing Address - Street 2:SUITE 100
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70508-5173
Mailing Address - Country:US
Mailing Address - Phone:337-330-0031
Mailing Address - Fax:337-330-0059
Practice Address - Street 1:1119 N MAIN ST
Practice Address - Street 2:
Practice Address - City:SAINT MARTINVILLE
Practice Address - State:LA
Practice Address - Zip Code:70582-3513
Practice Address - Country:US
Practice Address - Phone:337-394-7774
Practice Address - Fax:337-394-8015
Is Sole Proprietor?:No
Enumeration Date:2007-03-05
Last Update Date:2016-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAPA.200121363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1407208Medicaid
LA1407208Medicaid