Provider Demographics
NPI:1073547113
Name:ETCHETO, JOHN LAURENT (PA)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:LAURENT
Last Name:ETCHETO
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1740 BROOKFIELD CT
Mailing Address - Street 2:
Mailing Address - City:TWIN FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83301-3562
Mailing Address - Country:US
Mailing Address - Phone:208-736-2399
Mailing Address - Fax:
Practice Address - Street 1:176 FALLS AVENUE
Practice Address - Street 2:
Practice Address - City:TWIN FALLS
Practice Address - State:ID
Practice Address - Zip Code:83301
Practice Address - Country:US
Practice Address - Phone:208-733-3181
Practice Address - Fax:208-733-3168
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2022-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPA-476363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID806757300Medicaid
ID806757300Medicaid
IDQ02007Medicare UPIN