Provider Demographics
NPI:1104566678
Name:BOSTROM, COURTNEY LYN (MD)
Entity type:Individual
Prefix:
First Name:COURTNEY
Middle Name:LYN
Last Name:BOSTROM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2103 N ROBIN AVE
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55811-2018
Mailing Address - Country:US
Mailing Address - Phone:218-355-8707
Mailing Address - Fax:
Practice Address - Street 1:3500 GASTON AVE
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75246-2017
Practice Address - Country:US
Practice Address - Phone:214-820-0111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-31
Last Update Date:2022-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program