Provider Demographics
NPI:1902949340
Name:FAYRWEATHER, COURTNEY DANIEL (NP)
Entity Type:Individual
Prefix:
First Name:COURTNEY
Middle Name:DANIEL
Last Name:FAYRWEATHER
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12659 PINE BUSH DR
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77070-4748
Mailing Address - Country:US
Mailing Address - Phone:281-477-7784
Mailing Address - Fax:
Practice Address - Street 1:1635 NORTH LOOP W
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77008-1532
Practice Address - Country:US
Practice Address - Phone:713-867-2000
Practice Address - Fax:713-867-2099
Is Sole Proprietor?:No
Enumeration Date:2007-02-15
Last Update Date:2020-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX660890363LF0000X, 363L00000X
TXAP113345363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8Y0500OtherBLUE CROSS BLUE SHIELD