Provider Demographics
NPI:1982020186
Name:SULLENBERGER, COURTNEY (PA-C)
Entity Type:Individual
Prefix:
First Name:COURTNEY
Middle Name:
Last Name:SULLENBERGER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:COURTNEY
Other - Middle Name:KATHLEEN
Other - Last Name:DEMETER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:9651 N WANDA CT
Mailing Address - Street 2:
Mailing Address - City:MOORESVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46158-6131
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:747 E COUNTY LINE RD STE B
Practice Address - Street 2:
Practice Address - City:GREENWOOD
Practice Address - State:IN
Practice Address - Zip Code:46143-1082
Practice Address - Country:US
Practice Address - Phone:317-789-9600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-03-12
Last Update Date:2021-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN10001636A363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN264430199Medicare PIN