Provider Demographics
NPI:1437700101
Name:PATTON, CORTNIE L (NP)
Entity Type:Individual
Prefix:
First Name:CORTNIE
Middle Name:L
Last Name:PATTON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:CORTNIE
Other - Middle Name:L
Other - Last Name:JORDAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:NP
Mailing Address - Street 1:7619 W JEFFERSON BLVD
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46804-4133
Mailing Address - Country:US
Mailing Address - Phone:260-407-8000
Mailing Address - Fax:
Practice Address - Street 1:1721 MAGNAVOX
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804-1537
Practice Address - Country:US
Practice Address - Phone:260-748-3650
Practice Address - Fax:260-748-3651
Is Sole Proprietor?:No
Enumeration Date:2019-09-24
Last Update Date:2022-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28225685A163W00000X
IN71009770A363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300035248Medicaid