Provider Demographics
NPI:1447348545
Name:RICHTER, COURTNEY B (PA-C)
Entity type:Individual
Prefix:
First Name:COURTNEY
Middle Name:B
Last Name:RICHTER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:COURTNEY
Other - Middle Name:
Other - Last Name:BOEHME
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:4466 WEILERS WAY
Mailing Address - Street 2:
Mailing Address - City:PORT WASHINGTON
Mailing Address - State:WI
Mailing Address - Zip Code:53074-9608
Mailing Address - Country:US
Mailing Address - Phone:208-859-5606
Mailing Address - Fax:
Practice Address - Street 1:13111 N PORT WASHINGTON RD
Practice Address - Street 2:
Practice Address - City:MEQUON
Practice Address - State:WI
Practice Address - Zip Code:53097
Practice Address - Country:US
Practice Address - Phone:414-290-6720
Practice Address - Fax:414-290-6755
Is Sole Proprietor?:No
Enumeration Date:2006-10-11
Last Update Date:2022-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPA750363A00000X
WI2069363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1447348545Medicaid
ID808128200Medicaid
ID808128200Medicaid
Q73414Medicare UPIN