MEDICARE: COURTNEY AVRA PA

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	PA15238	TX

General Provider Information

NPI Number	:	1194485375
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	COURTNEY AVRA PA

Provider Business Mailing Address
First Line	:	3900 NE STALLINGS DR STE 101
Second Line	:
City	:	NACOGDOCHES
State	:	TX
Zip	:	75965-2111
Country	:	US
Telephone Number	:	936-559-8770
Fax Number	:	936-559-8773

Provider Business Practice Location Address
First Line	:	3900 NE STALLINGS DR STE 101
Second Line	:
City	:	NACOGDOCHES
State	:	TX
Zip	:	75965-2111
Country	:	US
Telephone Number	:	936-559-8770
Fax Number	:	936-559-8773

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

Provider Enumeration Date	:	12/29/2021
Last Update Date	:	12/29/2021

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Directions to “ COURTNEY AVRA PA” Practice Location

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