Provider Demographics
NPI:1982785762
Name:COURTNEY, SAMUEL MARK
Entity Type:Individual
Prefix:
First Name:SAMUEL
Middle Name:MARK
Last Name:COURTNEY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:420 HILLCREST AVE
Mailing Address - Street 2:
Mailing Address - City:GROVE CITY
Mailing Address - State:PA
Mailing Address - Zip Code:16127-1708
Mailing Address - Country:US
Mailing Address - Phone:724-458-4950
Mailing Address - Fax:
Practice Address - Street 1:420 HILLCREST AVE
Practice Address - Street 2:
Practice Address - City:GROVE CITY
Practice Address - State:PA
Practice Address - Zip Code:16127-1708
Practice Address - Country:US
Practice Address - Phone:724-458-4950
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-18
Last Update Date:2010-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA000897L363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical