Provider Demographics
NPI:1740819168
Name:KEVILLE, COURTNEY MARIE (PA-C)
Entity type:Individual
Prefix:MS
First Name:COURTNEY
Middle Name:MARIE
Last Name:KEVILLE
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 1:20 WILLETTA DR
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:NJ
Mailing Address - Zip Code:08527-4861
Mailing Address - Country:US
Mailing Address - Phone:908-910-1064
Mailing Address - Fax:
Practice Address - Street 1:600 RIVER AVE
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:08701-5237
Practice Address - Country:US
Practice Address - Phone:732-363-1900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-07
Last Update Date:2020-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY024814363A00000X
NJ25MP00562600363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant