Provider Demographics
NPI:1215698501
Name:COURTNEY, JOHN (BS, PTA)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:COURTNEY
Suffix:
Gender:M
Credentials:BS, PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4 SOUTHWOOD DR
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14223-1053
Mailing Address - Country:US
Mailing Address - Phone:716-480-2513
Mailing Address - Fax:
Practice Address - Street 1:4140 OLD WASHINGTON RD
Practice Address - Street 2:
Practice Address - City:WALDORF
Practice Address - State:MD
Practice Address - Zip Code:20602-3221
Practice Address - Country:US
Practice Address - Phone:301-645-2813
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-07
Last Update Date:2023-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA31465208100000X
COPTA.0015136208100000X
NY013082-01208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPTA31496OtherPTA LICENSE
NY013082-01OtherPTA LICENSE