Basic Information
| Provider Information | |||||||||
| NPI: | 1497359707 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PRIM | ||||||||
| FirstName: | COURTNEY | ||||||||
| MiddleName: | |||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 645 N MAIN ST | ||||||||
| Address2: | |||||||||
| City: | HIGH POINT | ||||||||
| State: | NC | ||||||||
| PostalCode: | 272605017 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3368830029 | ||||||||
| FaxNumber: | 3368830867 | ||||||||
| Practice Location | |||||||||
| Address1: | 190 INDEPENDENCE AVE STE B | ||||||||
| Address2: | |||||||||
| City: | NORTH WILKESBORO | ||||||||
| State: | NC | ||||||||
| PostalCode: | 286594270 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3368830029 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/27/2020 | ||||||||
| LastUpdateDate: | 12/14/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/14/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 0010-10727 | NC | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 208VP0000X | 0010-10727 | NC | Y | Allopathic & Osteopathic Physicians | Pain Medicine | Pain Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0010-10727 | 01 | NC | NC STATE LICENSE | OTHER |