Provider Demographics
NPI:1598058331
Name:MEINDERS, COURTNEY NICOLE (PA)
Entity Type:Individual
Prefix:MRS
First Name:COURTNEY
Middle Name:NICOLE
Last Name:MEINDERS
Suffix:
Gender:F
Credentials:PA
Other - Prefix:MS
Other - First Name:COURTNEY
Other - Middle Name:NICOLE
Other - Last Name:RICCI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:4545 ALAMEDA BLVD NE STE G
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87113-1591
Mailing Address - Country:US
Mailing Address - Phone:505-896-2900
Mailing Address - Fax:505-938-4198
Practice Address - Street 1:4545 ALAMEDA BLVD NE STE G
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87113-1591
Practice Address - Country:US
Practice Address - Phone:505-896-2900
Practice Address - Fax:505-938-4198
Is Sole Proprietor?:No
Enumeration Date:2011-05-26
Last Update Date:2021-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPA.0004740363A00000X
RIPA00792363AM0700X
NMPA2021-0032363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
COPA.0004740OtherLICENSE
AL762OtherSTATE PA LICENSE
RIPA00792OtherSTATE LICENSE