Provider Demographics
NPI:1487316410
Name:CAMPBELL, COURTNEY NICOLE (PA)
Entity type:Individual
Prefix:
First Name:COURTNEY
Middle Name:NICOLE
Last Name:CAMPBELL
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:333 VESTA CT
Mailing Address - Street 2:
Mailing Address - City:RIDGEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:07450-2617
Mailing Address - Country:US
Mailing Address - Phone:201-686-6900
Mailing Address - Fax:
Practice Address - Street 1:5 COLUMBUS CIRCLE
Practice Address - Street 2:FLOOR 8
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10019
Practice Address - Country:US
Practice Address - Phone:212-664-9323
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-07
Last Update Date:2021-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY027419363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant