Provider Demographics
NPI:1942696521
Name:MATKOVICH, COURTNEY R (CRNP)
Entity Type:Individual
Prefix:
First Name:COURTNEY
Middle Name:R
Last Name:MATKOVICH
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:145 W 23RD ST STE 202
Mailing Address - Street 2:
Mailing Address - City:ERIE
Mailing Address - State:PA
Mailing Address - Zip Code:16502-2858
Mailing Address - Country:US
Mailing Address - Phone:814-452-5081
Mailing Address - Fax:814-452-7918
Practice Address - Street 1:145 W 23RD ST STE 202
Practice Address - Street 2:
Practice Address - City:ERIE
Practice Address - State:PA
Practice Address - Zip Code:16502-2858
Practice Address - Country:US
Practice Address - Phone:814-452-5081
Practice Address - Fax:814-452-7918
Is Sole Proprietor?:No
Enumeration Date:2015-04-10
Last Update Date:2020-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP014832363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1030224520002Medicaid