Provider Demographics
NPI:1740499961
Name:EDGAR-ZARATE, COURTNEY LEANN (MD)
Entity type:Individual
Prefix:
First Name:COURTNEY
Middle Name:LEANN
Last Name:EDGAR-ZARATE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:COURTNEY
Other - Middle Name:LEANN
Other - Last Name:EDGAR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:1 CHILDRENS WAY # 653
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72202-3500
Mailing Address - Country:US
Mailing Address - Phone:501-364-1100
Mailing Address - Fax:501-364-2963
Practice Address - Street 1:800 ROSE ST
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40536-7001
Practice Address - Country:US
Practice Address - Phone:859-218-2581
Practice Address - Fax:859-257-1632
Is Sole Proprietor?:No
Enumeration Date:2007-05-22
Last Update Date:2022-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE-7767208000000X
SC32069207R00000X
OH35.091055390200000X
OH57012028390200000X
KY56336208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR280477OtherMEDICARE PTAN