Provider Demographics
NPI:1255870556
Name:PAYNE, COURTNEY (PA)
Entity Type:Individual
Prefix:MRS
First Name:COURTNEY
Middle Name:
Last Name:PAYNE
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:COURTNEY
Other - Middle Name:
Other - Last Name:MOYER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:157 N STATE ROUTE 510
Mailing Address - Street 2:
Mailing Address - City:FREMONT
Mailing Address - State:OH
Mailing Address - Zip Code:43420-9224
Mailing Address - Country:US
Mailing Address - Phone:419-217-1614
Mailing Address - Fax:
Practice Address - Street 1:2120 W CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43606-3834
Practice Address - Country:US
Practice Address - Phone:419-824-1785
Practice Address - Fax:419-824-5953
Is Sole Proprietor?:No
Enumeration Date:2017-02-20
Last Update Date:2023-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50.004996RX363AM0700X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHH487640OtherMEDICARE PIN
OH0209103Medicaid