Provider Demographics
NPI:1588333447
Name:MILLESON, COURTNEY KEITH (PA)
Entity type:Individual
Prefix:
First Name:COURTNEY
Middle Name:KEITH
Last Name:MILLESON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:195 KIMEL PARK DR STE 200
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27103-6967
Mailing Address - Country:US
Mailing Address - Phone:336-768-6211
Mailing Address - Fax:336-768-6869
Practice Address - Street 1:195 KIMEL PARK DR STE 200
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-6967
Practice Address - Country:US
Practice Address - Phone:336-768-6211
Practice Address - Fax:336-768-6869
Is Sole Proprietor?:No
Enumeration Date:2021-09-13
Last Update Date:2024-08-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NC0010-11603363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant