Provider Demographics
NPI:1255582516
Name:EGGLESTON, COURTNEY LEE (PA)
Entity type:Individual
Prefix:
First Name:COURTNEY
Middle Name:LEE
Last Name:EGGLESTON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:COURTNEY
Other - Middle Name:LEE
Other - Last Name:ROSS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:1001 W FAYETTE ST
Mailing Address - Street 2:SUITE 400
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13204-2859
Mailing Address - Country:US
Mailing Address - Phone:315-470-7409
Mailing Address - Fax:315-475-2357
Practice Address - Street 1:739 IRVING AVE
Practice Address - Street 2:SUITE 500
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13210-1651
Practice Address - Country:US
Practice Address - Phone:315-470-7409
Practice Address - Fax:315-475-2357
Is Sole Proprietor?:No
Enumeration Date:2008-10-06
Last Update Date:2016-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY012856363A00000X
PAMA055386363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03061929Medicaid
NY03061929Medicaid