Healthcare Provider Details

I. General information

NPI: 1811044209
Provider Name (Legal Business Name): EILEEN SHANNON COURTLEIGH P.A.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: EILEEN SHANNON HUBBARD PA

II. Dates (important events)

Enumeration Date: 01/05/2007
Last Update Date: 12/01/2022
Certification Date: 12/01/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

724 S HORNER BLVD
SANFORD NC
27330-4822
US

IV. Provider business mailing address

5000 COX RD
GLEN ALLEN VA
23060-9263
US

V. Phone/Fax

Practice location:
  • Phone: 919-776-6767
  • Fax: 919-776-6773
Mailing address:
  • Phone: 804-968-5700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberMA002587L
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0010-11470
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: