Provider Demographics
NPI:1467638809
Name:MORTIMER, KORTNEY (PA)
Entity Type:Individual
Prefix:
First Name:KORTNEY
Middle Name:
Last Name:MORTIMER
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 15645
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89114-5645
Mailing Address - Country:US
Mailing Address - Phone:702-877-8330
Mailing Address - Fax:702-877-8312
Practice Address - Street 1:2316 W CHARLESTON BLVD
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89102-2149
Practice Address - Country:US
Practice Address - Phone:702-877-8330
Practice Address - Fax:702-877-8312
Is Sole Proprietor?:No
Enumeration Date:2008-01-16
Last Update Date:2023-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVPA1339363AM0700X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1467638809Medicaid
NVGN485ZMedicare PIN