MEDICARE: COURTNEY DIANA KIRKLAND

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	PA5976963	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	8NL737	OTHER	TX	BCBSTX
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1083278311
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	COURTNEY DIANA KIRKLAND

Provider Business Mailing Address
First Line	:	PO BOX 2347
Second Line	:
City	:	DECATUR
State	:	TX
Zip	:	76234-6161
Country	:	US
Telephone Number	:	940-626-8073
Fax Number	:	940-626-8137

Provider Business Practice Location Address
First Line	:	2351 S FM 51 STE 100
Second Line	:
City	:	DECATUR
State	:	TX
Zip	:	76234-3778
Country	:	US
Telephone Number	:	940-626-8073
Fax Number	:	940-626-8137

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/22/2019
Last Update Date	:	11/16/2020

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Directions to “ COURTNEY DIANA KIRKLAND ” Practice Location

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