Provider Demographics
NPI:1932838307
Name:COURTNEY, EVAN KELLY (PA-C)
Entity Type:Individual
Prefix:
First Name:EVAN
Middle Name:KELLY
Last Name:COURTNEY
Suffix:
Gender:M
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 1:1619 CREIGHTON RD STE 1
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32504-7152
Mailing Address - Country:US
Mailing Address - Phone:850-444-4700
Mailing Address - Fax:850-444-7497
Practice Address - Street 1:1619 CREIGHTON RD STE 1
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32504-7152
Practice Address - Country:US
Practice Address - Phone:850-444-4700
Practice Address - Fax:850-444-7497
Is Sole Proprietor?:No
Enumeration Date:2022-06-09
Last Update Date:2022-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
FLPA9116453363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant