Provider Demographics
NPI:1265486732
Name:COURTNEY, MEGAN AUDRA (PA-C, ATC)
Entity Type:Individual
Prefix:MISS
First Name:MEGAN
Middle Name:AUDRA
Last Name:COURTNEY
Suffix:
Gender:F
Credentials:PA-C, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6420 DUTCHMANS PKWY STE 205
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40205-3372
Mailing Address - Country:US
Mailing Address - Phone:502-242-6370
Mailing Address - Fax:502-242-6540
Practice Address - Street 1:6420 DUTCHMANS PKWY STE 205
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40205-3372
Practice Address - Country:US
Practice Address - Phone:502-242-6370
Practice Address - Fax:502-242-6540
Is Sole Proprietor?:No
Enumeration Date:2006-05-20
Last Update Date:2021-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYPA1655363AM0700X, 363A00000X, 363AS0400X
IN10001823A363A00000X, 363AM0700X, 363AS0400X, 363A00000X
IN10001823B363A00000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100193870Medicaid
KYP01122799OtherRR MEDICARE
KY000000728596OtherANTHEM BC/BS
IN300008425Medicaid
KY000000728596OtherANTHEM BC/BS
KYP01122799OtherRR MEDICARE
IN201275440Medicaid