Provider Demographics
NPI:1205095809
Name:STANLEY, COURTNEY GIBBS (PA)
Entity type:Individual
Prefix:
First Name:COURTNEY
Middle Name:GIBBS
Last Name:STANLEY
Suffix:
Gender:F
Credentials:PA
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 1479
Mailing Address - Street 2:
Mailing Address - City:LAKE CITY
Mailing Address - State:SC
Mailing Address - Zip Code:29560-1479
Mailing Address - Country:US
Mailing Address - Phone:843-374-6256
Mailing Address - Fax:
Practice Address - Street 1:325 MERCY ST
Practice Address - Street 2:
Practice Address - City:LAKE CITY
Practice Address - State:SC
Practice Address - Zip Code:29560-2331
Practice Address - Country:US
Practice Address - Phone:843-374-6256
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-09
Last Update Date:2008-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1297363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC1297OtherSTATE LICENSE #