Provider Demographics
NPI:1558023317
Name:ZAK, COURTNEY (PA-C)
Entity Type:Individual
Prefix:
First Name:COURTNEY
Middle Name:
Last Name:ZAK
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 1:10511 GOLF COURSE RD NW STE 204
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87114-5917
Mailing Address - Country:US
Mailing Address - Phone:505-727-4430
Mailing Address - Fax:
Practice Address - Street 1:2100 LOUISIANA BLVD NE STE 401
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87110-5419
Practice Address - Country:US
Practice Address - Phone:505-724-4300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-08
Last Update Date:2023-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363AM0700X
NMPA2021-0115363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM80039251Medicaid