Healthcare Provider Details

I. General information

NPI: 1487316410
Provider Name (Legal Business Name): COURTNEY NICOLE CAMPBELL PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/07/2021
Last Update Date: 10/07/2021
Certification Date: 10/07/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5 COLUMBUS CIRCLE FLOOR 8
NEW YORK NY
10019
US

IV. Provider business mailing address

333 VESTA CT
RIDGEWOOD NJ
07450-2617
US

V. Phone/Fax

Practice location:
  • Phone: 212-664-9323
  • Fax:
Mailing address:
  • Phone: 201-686-6900
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number027419
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: