Provider Demographics
NPI:1275500977
Name:WARREN, COURTNEY L (PA-C)
Entity Type:Individual
Prefix:
First Name:COURTNEY
Middle Name:L
Last Name:WARREN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:COURTNEY
Other - Middle Name:L
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:3033 S 27TH ST
Mailing Address - Street 2:SUITE 202
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53215-3600
Mailing Address - Country:US
Mailing Address - Phone:414-908-6615
Mailing Address - Fax:414-385-2980
Practice Address - Street 1:1033 N MAYFAIR RD
Practice Address - Street 2:SUITE 101
Practice Address - City:WAUWATOSA
Practice Address - State:WI
Practice Address - Zip Code:53226-3442
Practice Address - Country:US
Practice Address - Phone:414-454-0600
Practice Address - Fax:414-454-0971
Is Sole Proprietor?:No
Enumeration Date:2006-03-02
Last Update Date:2013-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1467-023363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIP70446Medicare UPIN
WI005473844Medicare PIN
WI005252540Medicare PIN