Provider Demographics
NPI:1215982780
Name:BOLLUYT, COURTNEY N (PA-C)
Entity type:Individual
Prefix:
First Name:COURTNEY
Middle Name:N
Last Name:BOLLUYT
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4950 S MINNESOTA AVE
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57108-2708
Mailing Address - Country:US
Mailing Address - Phone:605-330-9619
Mailing Address - Fax:605-330-9503
Practice Address - Street 1:2700 23RD ST STE C
Practice Address - Street 2:
Practice Address - City:SPIRIT LAKE
Practice Address - State:IA
Practice Address - Zip Code:51360-1158
Practice Address - Country:US
Practice Address - Phone:605-330-9619
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-23
Last Update Date:2022-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA001337363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IAI8960Medicare ID - Type Unspecified