Provider Demographics
NPI:1336639756
Name:SHAY, COURTNEY LYNNE
Entity Type:Individual
Prefix:
First Name:COURTNEY
Middle Name:LYNNE
Last Name:SHAY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 743749
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90074-3749
Mailing Address - Country:US
Mailing Address - Phone:628-206-8000
Mailing Address - Fax:415-502-8175
Practice Address - Street 1:1001 POTRERO AVENUE
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94110-3518
Practice Address - Country:US
Practice Address - Phone:628-206-5753
Practice Address - Fax:628-206-5818
Is Sole Proprietor?:No
Enumeration Date:2018-05-10
Last Update Date:2022-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CAA175200207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program