Provider Demographics
NPI:1720624042
Name:UMPHRESS, COURTNEY T (PA-C)
Entity Type:Individual
Prefix:
First Name:COURTNEY
Middle Name:T
Last Name:UMPHRESS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5013 S LOUISE AVE # 30538
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57108-2268
Mailing Address - Country:US
Mailing Address - Phone:847-942-0727
Mailing Address - Fax:
Practice Address - Street 1:1298 W FINNIE FLAT RD
Practice Address - Street 2:
Practice Address - City:CAMP VERDE
Practice Address - State:AZ
Practice Address - Zip Code:86322-5958
Practice Address - Country:US
Practice Address - Phone:928-639-5555
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-21
Last Update Date:2024-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN10002869A363A00000X
ORPA213392363A00000X
AZ10156363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300032838Medicaid