Provider Demographics
NPI:1881870657
Name:LOPER, COURTNEY LANE (PAC)
Entity type:Individual
Prefix:MS
First Name:COURTNEY
Middle Name:LANE
Last Name:LOPER
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:COURTNEY
Other - Middle Name:LANE
Other - Last Name:HOOD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PAC
Mailing Address - Street 1:1024 MAR WALT DR
Mailing Address - Street 2:
Mailing Address - City:FORT WALTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32547-6645
Mailing Address - Country:US
Mailing Address - Phone:850-863-3148
Mailing Address - Fax:
Practice Address - Street 1:1024 MAR WALT DR
Practice Address - Street 2:
Practice Address - City:FORT WALTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:32547-6645
Practice Address - Country:US
Practice Address - Phone:850-863-3148
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-01-11
Last Update Date:2017-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC001001101363A00000X
NVPA1523363A00000X
FLPA9110566363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant