Provider Demographics
NPI:1396707915
Name:HARRELL, COURTNEY
Entity type:Individual
Prefix:
First Name:COURTNEY
Middle Name:
Last Name:HARRELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7301 BURNET RD
Mailing Address - Street 2:SUITE 102-192
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78757-2250
Mailing Address - Country:US
Mailing Address - Phone:512-784-8499
Mailing Address - Fax:
Practice Address - Street 1:1301 WONDER WORLD DR
Practice Address - Street 2:
Practice Address - City:SAN MARCOS
Practice Address - State:TX
Practice Address - Zip Code:78666-7533
Practice Address - Country:US
Practice Address - Phone:512-753-3571
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX608039367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX85917UOtherBLUE SHIELD
TX85917UOtherBLUE SHIELD
TXS71892Medicare UPIN