Provider Demographics
NPI:1598135709
Name:MCNULTY, COURTNEY MARIE (PA-C)
Entity type:Individual
Prefix:
First Name:COURTNEY
Middle Name:MARIE
Last Name:MCNULTY
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 1:3 W OLIVE ST
Mailing Address - Street 2:SUITE 118
Mailing Address - City:SCRANTON
Mailing Address - State:PA
Mailing Address - Zip Code:18508-2572
Mailing Address - Country:US
Mailing Address - Phone:570-961-3823
Mailing Address - Fax:570-207-5988
Practice Address - Street 1:3 W OLIVE ST
Practice Address - Street 2:SUITE 118
Practice Address - City:SCRANTON
Practice Address - State:PA
Practice Address - Zip Code:18508-2572
Practice Address - Country:US
Practice Address - Phone:570-961-3823
Practice Address - Fax:570-207-5988
Is Sole Proprietor?:No
Enumeration Date:2015-09-30
Last Update Date:2015-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOA003655363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant