Provider Demographics
NPI:1104282920
Name:SUPON, COURTNEY HELMAN (RN, FNP-C)
Entity type:Individual
Prefix:
First Name:COURTNEY
Middle Name:HELMAN
Last Name:SUPON
Suffix:
Gender:F
Credentials:RN, FNP-C
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Mailing Address - Street 1:4515 SETON CENTER PKWY
Mailing Address - Street 2:SUITE 215
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78759-5290
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6835 AUSTIN CENTER BLVD
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78731-3166
Practice Address - Country:US
Practice Address - Phone:512-346-6611
Practice Address - Fax:512-406-7315
Is Sole Proprietor?:No
Enumeration Date:2016-01-08
Last Update Date:2018-02-01
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
CA95003474363LF0000X
TXAP129597363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX358112602Medicaid
TX358112601Medicaid
TX498893YKXYMedicare PIN
TX358112602Medicaid