Healthcare Provider Details

I. General information

NPI: 1720333891
Provider Name (Legal Business Name): COURTENAY E DEANE DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/16/2012
Last Update Date: 07/21/2022
Certification Date: 11/19/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

320 E MAIN ST
CROSBY MN
56441-1645
US

IV. Provider business mailing address

320 EAST MAIN STREET
CROSBY MN
56441
US

V. Phone/Fax

Practice location:
  • Phone: 218-546-7000
  • Fax: 218-546-4400
Mailing address:
  • Phone: 218-546-7000
  • Fax: 218-546-4400

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code204D00000X
TaxonomyNeuromusculoskeletal Medicine & OMM Physician
License NumberDO2702
License Number StateME
# 2
Primary TaxonomyY
Taxonomy Code204D00000X
TaxonomyNeuromusculoskeletal Medicine & OMM Physician
License Number62113
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: