Provider Demographics
NPI:1679010060
Name:GUTSCHENRITTER, COURTNEY LEIGH
Entity Type:Individual
Prefix:
First Name:COURTNEY
Middle Name:LEIGH
Last Name:GUTSCHENRITTER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:COURTNEY
Other - Middle Name:LEIGH
Other - Last Name:CASS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 26901
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73126-0901
Mailing Address - Country:US
Mailing Address - Phone:405-271-4351
Mailing Address - Fax:
Practice Address - Street 1:920 STANTON L YOUNG BLVD # WP1140
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73104-5036
Practice Address - Country:US
Practice Address - Phone:405-271-4351
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-01-24
Last Update Date:2024-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA60936256363A00000X
OK2702363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1679010060Medicaid