Provider Demographics
NPI:1811044209
Name:COURTLEIGH, EILEEN SHANNON (PA)
Entity Type:Individual
Prefix:
First Name:EILEEN
Middle Name:SHANNON
Last Name:COURTLEIGH
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:EILEEN
Other - Middle Name:SHANNON
Other - Last Name:HUBBARD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:5000 COX RD
Mailing Address - Street 2:
Mailing Address - City:GLEN ALLEN
Mailing Address - State:VA
Mailing Address - Zip Code:23060-9263
Mailing Address - Country:US
Mailing Address - Phone:804-968-5700
Mailing Address - Fax:
Practice Address - Street 1:724 S HORNER BLVD
Practice Address - Street 2:
Practice Address - City:SANFORD
Practice Address - State:NC
Practice Address - Zip Code:27330-4822
Practice Address - Country:US
Practice Address - Phone:919-776-6767
Practice Address - Fax:919-776-6773
Is Sole Proprietor?:No
Enumeration Date:2007-01-05
Last Update Date:2022-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA002587L363A00000X
NC0010-11470363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant