Provider Demographics
NPI:1699743872
Name:CONVERSE, COURTNEY L (PA-C)
Entity type:Individual
Prefix:
First Name:COURTNEY
Middle Name:L
Last Name:CONVERSE
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 1:801 YORK ST
Mailing Address - Street 2:
Mailing Address - City:MANITOWOC
Mailing Address - State:WI
Mailing Address - Zip Code:54220-4630
Mailing Address - Country:US
Mailing Address - Phone:920-663-9008
Mailing Address - Fax:920-684-1439
Practice Address - Street 1:535 S BURDICK ST STE 256
Practice Address - Street 2:
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49007-6112
Practice Address - Country:US
Practice Address - Phone:269-290-1901
Practice Address - Fax:269-290-1913
Is Sole Proprietor?:No
Enumeration Date:2006-03-14
Last Update Date:2022-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601004349363AS0400X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1417961137OtherBCBS - BRONSON
MI1699743872Medicaid
Q57205Medicare UPIN
MIC97618294 - BRONSONMedicare PIN
MI1699743872Medicaid