Provider Demographics
NPI:1851862544
Name:HUBERT, COURTNEY L (PA-C)
Entity Type:Individual
Prefix:
First Name:COURTNEY
Middle Name:L
Last Name:HUBERT
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:PO BOX 5074
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57117-5074
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1500 W 22ND ST STE 301
Practice Address - Street 2:
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57105-1503
Practice Address - Country:US
Practice Address - Phone:605-328-7700
Practice Address - Fax:605-328-7775
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-06
Last Update Date:2020-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD1243363A00000X
MI5601008846363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD1243OtherPHYSICIAN ASSISTANT LICENSE
MI5601008846OtherPHYSICIAN'S ASSISTANT LICENSE