Healthcare Provider Details

I. General information

NPI: 1902900376
Provider Name (Legal Business Name): COURTNEY J SMITH PAC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: COURTNEY BULL

II. Dates (important events)

Enumeration Date: 09/07/2006
Last Update Date: 02/28/2020
Certification Date: 02/28/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1885 PLAZA DR
EAGAN MN
55122-2979
US

IV. Provider business mailing address

1885 PLAZA DR
EAGAN MN
55122-2979
US

V. Phone/Fax

Practice location:
  • Phone: 952-993-4069
  • Fax: 952-993-4095
Mailing address:
  • Phone: 952-993-4069
  • Fax: 952-993-4095

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number10170
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: