Provider Demographics
NPI:1417208505
Name:TELLER, COURTNEY L (PA-C)
Entity Type:Individual
Prefix:
First Name:COURTNEY
Middle Name:L
Last Name:TELLER
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 1:102 S HENNEPIN AVE
Mailing Address - Street 2:
Mailing Address - City:DIXON
Mailing Address - State:IL
Mailing Address - Zip Code:61021-3013
Mailing Address - Country:US
Mailing Address - Phone:815-285-8523
Mailing Address - Fax:815-285-8901
Practice Address - Street 1:102 S HENNEPIN AVE
Practice Address - Street 2:
Practice Address - City:DIXON
Practice Address - State:IL
Practice Address - Zip Code:61021-3013
Practice Address - Country:US
Practice Address - Phone:815-285-8523
Practice Address - Fax:815-285-8901
Is Sole Proprietor?:No
Enumeration Date:2012-09-28
Last Update Date:2018-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085004426363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL381220033OtherMEDICARE
IL329785745001Medicaid