Provider Demographics
NPI:1861461329
Name:WHITNEY, COURTNEY WADE (DO)
Entity Type:Individual
Prefix:DR
First Name:COURTNEY
Middle Name:WADE
Last Name:WHITNEY
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2700 CAMPUS DRIVE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:PLYMOUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55441
Mailing Address - Country:US
Mailing Address - Phone:763-319-0634
Mailing Address - Fax:763-519-0636
Practice Address - Street 1:2700 CAMPUS DRIVE
Practice Address - Street 2:SUITE 100
Practice Address - City:PLYMOUTH
Practice Address - State:MN
Practice Address - Zip Code:55441
Practice Address - Country:US
Practice Address - Phone:763-519-0634
Practice Address - Fax:763-519-0636
Is Sole Proprietor?:No
Enumeration Date:2006-03-16
Last Update Date:2012-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN39456207R00000X, 207RS0012X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RS0012XAllopathic & Osteopathic PhysiciansInternal MedicineSleep Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN376913000Medicaid
MN991942200Medicaid
MNHP27198OtherHEALTH PARTNERS
MNG77760Medicare UPIN
110009413Medicare PIN
G77760Medicare UPIN
MN376913000Medicaid