Provider Demographics
NPI:1376808790
Name:EKLUND, COURTNEY M (PAC)
Entity Type:Individual
Prefix:
First Name:COURTNEY
Middle Name:M
Last Name:EKLUND
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4320 WORNALL RD STE 50
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64111-5943
Mailing Address - Country:US
Mailing Address - Phone:816-931-3312
Mailing Address - Fax:816-531-9862
Practice Address - Street 1:4320 WORNALL RD STE 50
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64111-5943
Practice Address - Country:US
Practice Address - Phone:816-931-3312
Practice Address - Fax:816-531-9862
Is Sole Proprietor?:No
Enumeration Date:2012-07-11
Last Update Date:2022-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085004437363A00000X
MO2014009308363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL214881Medicare Oscar/Certification