Provider Demographics
NPI:1417046459
Name:LEE, COURTNEY MARIE (PA-C)
Entity type:Individual
Prefix:
First Name:COURTNEY
Middle Name:MARIE
Last Name:LEE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:COURTNEY
Other - Middle Name:MARIE
Other - Last Name:KOEHNEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1650 COWLES ST
Mailing Address - Street 2:
Mailing Address - City:FAIRBANKS
Mailing Address - State:AK
Mailing Address - Zip Code:99701-5907
Mailing Address - Country:US
Mailing Address - Phone:907-458-6450
Mailing Address - Fax:907-458-6430
Practice Address - Street 1:1650 COWLES ST
Practice Address - Street 2:
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99701-5907
Practice Address - Country:US
Practice Address - Phone:907-458-6450
Practice Address - Fax:907-458-6430
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-11
Last Update Date:2025-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
AK178921363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK1755878Medicaid