Basic Information
Provider Information | |||||||||
NPI: | 1538278213 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MCCOURTIE | ||||||||
FirstName: | ANTON | ||||||||
MiddleName: | STUART | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 529 JASMINE ST | ||||||||
Address2: |   | ||||||||
City: | OMAK | ||||||||
State: | WA | ||||||||
PostalCode: | 988419589 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5098261600 | ||||||||
FaxNumber: | 5098263633 | ||||||||
Practice Location | |||||||||
Address1: | 529 JASMINE ST | ||||||||
Address2: |   | ||||||||
City: | OMAK | ||||||||
State: | WA | ||||||||
PostalCode: | 988419589 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5098261600 | ||||||||
FaxNumber: | 5098263633 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/29/2006 | ||||||||
LastUpdateDate: | 03/19/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | ML20008639 | WA | N |   | Allopathic & Osteopathic Physicians | Surgery |   | 208600000X | MD60227253 | WA | Y |   | Allopathic & Osteopathic Physicians | Surgery |   |
ID Information
ID | Type | State | Issuer | Description | 0297859 | 01 | WA | L&I | OTHER | 1538278213 | 05 | WA |   | MEDICAID | P01082422 | 01 | WA | RR MEDICARE | OTHER |