Provider Demographics
NPI:1245872399
Name:BURGESS, COURTLYN (PA-C)
Entity type:Individual
Prefix:
First Name:COURTLYN
Middle Name:
Last Name:BURGESS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:COURTLYN
Other - Middle Name:
Other - Last Name:HOLLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:246 LEMUR DR
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78213-3435
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1100 WILFORD HALL LOOP
Practice Address - Street 2:
Practice Address - City:JBSA LACKLAND
Practice Address - State:TX
Practice Address - Zip Code:78236-5638
Practice Address - Country:US
Practice Address - Phone:210-292-4277
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-10
Last Update Date:2022-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA13245363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant