Provider Demographics
NPI:1629535307
Name:CRISWELL, COURTNEY RAE (PA-C)
Entity Type:Individual
Prefix:
First Name:COURTNEY
Middle Name:RAE
Last Name:CRISWELL
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:COURTNEY
Other - Middle Name:R
Other - Last Name:DAVIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5191 FIRST COAST TECH PKWY FL 3
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32224-0609
Mailing Address - Country:US
Mailing Address - Phone:904-223-3321
Mailing Address - Fax:904-223-2169
Practice Address - Street 1:5191 FIRST COAST TECH PKWY FL 3
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32224-0609
Practice Address - Country:US
Practice Address - Phone:904-223-3321
Practice Address - Fax:904-223-2169
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-28
Last Update Date:2024-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9111862363A00000X
GA10406363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant