Basic Information
| Provider Information | |||||||||
| NPI: | 1053878595 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DECKER | ||||||||
| FirstName: | COURTNEY | ||||||||
| MiddleName: | ELIZABETH | ||||||||
| NamePrefix: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MCKEEVER | ||||||||
| OtherFirstName: | COURTNEY | ||||||||
| OtherMiddleName: | |||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1104 21ST ST | ||||||||
| Address2: | |||||||||
| City: | REEDSBURG | ||||||||
| State: | WI | ||||||||
| PostalCode: | 539591156 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6085246487 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1104 21ST ST | ||||||||
| Address2: | |||||||||
| City: | REEDSBURG | ||||||||
| State: | WI | ||||||||
| PostalCode: | 539591156 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6085246487 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/20/2019 | ||||||||
| LastUpdateDate: | 10/27/2022 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 10/27/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 5113-23 | WI | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.