Provider Demographics
NPI:1538518899
Name:BANNICK, COURTNEY HOBZA (MD)
Entity Type:Individual
Prefix:DR
First Name:COURTNEY
Middle Name:HOBZA
Last Name:BANNICK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:COURTNEY
Other - Middle Name:ELIZABETH
Other - Last Name:HOBZA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:444 W FORT ST.
Mailing Address - Street 2:CRH 2ND FLOOR
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83702-4535
Mailing Address - Country:US
Mailing Address - Phone:208-422-1018
Mailing Address - Fax:
Practice Address - Street 1:444 W FORT ST.
Practice Address - Street 2:CRH 2ND FLOOR
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83702-4535
Practice Address - Country:US
Practice Address - Phone:208-422-1018
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-08
Last Update Date:2023-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXR6654207Q00000X
KS04-44308207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX399302401Medicaid