Provider Demographics
NPI:1275815987
Name:MACIEL, COURTNEY (PA-C)
Entity Type:Individual
Prefix:
First Name:COURTNEY
Middle Name:
Last Name:MACIEL
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 1:800 N TUSTIN AVE STE A
Mailing Address - Street 2:
Mailing Address - City:SANTA ANA
Mailing Address - State:CA
Mailing Address - Zip Code:92705-3605
Mailing Address - Country:US
Mailing Address - Phone:714-245-0800
Mailing Address - Fax:
Practice Address - Street 1:800 N TUSTIN AVE STE A
Practice Address - Street 2:
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92705-3605
Practice Address - Country:US
Practice Address - Phone:714-245-0800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-09-20
Last Update Date:2014-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA21831363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical