Provider Demographics
NPI:1528048840
Name:PIKE, COURTNEY D (PA)
Entity type:Individual
Prefix:
First Name:COURTNEY
Middle Name:D
Last Name:PIKE
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 1:2600 N WOODLAWN ST
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67220-2729
Mailing Address - Country:US
Mailing Address - Phone:316-684-3838
Mailing Address - Fax:316-858-2530
Practice Address - Street 1:2600 N WOODLAWN ST
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67220-2729
Practice Address - Country:US
Practice Address - Phone:316-684-3838
Practice Address - Fax:316-858-2530
Is Sole Proprietor?:No
Enumeration Date:2006-01-20
Last Update Date:2008-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS15-00934363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KSP98900Medicare UPIN
KS426867Medicare ID - Type Unspecified