Healthcare Provider Details

I. General information

NPI: 1861461329
Provider Name (Legal Business Name): COURTNEY WADE WHITNEY D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/16/2006
Last Update Date: 01/20/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2700 CAMPUS DRIVE SUITE 100
PLYMOUTH MN
55441
US

IV. Provider business mailing address

2700 CAMPUS DRIVE SUITE 100
PLYMOUTH MN
55441
US

V. Phone/Fax

Practice location:
  • Phone: 763-519-0634
  • Fax: 763-519-0636
Mailing address:
  • Phone: 763-319-0634
  • Fax: 763-519-0636

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number39456
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code207RS0012X
TaxonomySleep Medicine (Internal Medicine) Physician
License Number39456
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: