Provider Demographics
NPI:1386688877
Name:PECK, COURTNEY (PA)
Entity Type:Individual
Prefix:
First Name:COURTNEY
Middle Name:
Last Name:PECK
Suffix:
Gender:F
Credentials:PA
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 1119
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02901-1119
Mailing Address - Country:US
Mailing Address - Phone:401-849-6868
Mailing Address - Fax:401-847-3840
Practice Address - Street 1:19 FRIENDSHIP ST
Practice Address - Street 2:
Practice Address - City:NEWPORT
Practice Address - State:RI
Practice Address - Zip Code:02840-2272
Practice Address - Country:US
Practice Address - Phone:401-849-6868
Practice Address - Fax:401-847-3840
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-15
Last Update Date:2012-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RI00239363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
1780672709OtherGROUP NPI#
RI007008385Medicare ID - Type Unspecified
P03519Medicare UPIN