Provider Demographics
NPI:1023019916
Name:LEDBETTER, COURTNEY Y (PA-C)
Entity type:Individual
Prefix:MRS
First Name:COURTNEY
Middle Name:Y
Last Name:LEDBETTER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13245 KESSLER RD
Mailing Address - Street 2:
Mailing Address - City:CAIRO
Mailing Address - State:IL
Mailing Address - Zip Code:62914-3101
Mailing Address - Country:US
Mailing Address - Phone:618-734-4400
Mailing Address - Fax:618-734-2884
Practice Address - Street 1:13245 KESSLER RD
Practice Address - Street 2:
Practice Address - City:CAIRO
Practice Address - State:IL
Practice Address - Zip Code:62914-3101
Practice Address - Country:US
Practice Address - Phone:618-734-4400
Practice Address - Fax:618-734-2884
Is Sole Proprietor?:No
Enumeration Date:2005-08-02
Last Update Date:2009-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085-001657363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL085001657Medicaid
Q25396Medicare UPIN
ILQ25396Medicare PIN
K10904Medicare ID - Type Unspecified