Provider Demographics
NPI:1083359103
Name:ETTA, PATRICK DANNY (MD)
Entity Type:Individual
Prefix:
First Name:PATRICK
Middle Name:DANNY
Last Name:ETTA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5531 S PICCADILLY
Mailing Address - Street 2:
Mailing Address - City:WEST BLOOMFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48322-1449
Mailing Address - Country:US
Mailing Address - Phone:248-756-0384
Mailing Address - Fax:
Practice Address - Street 1:2799 W GRAND BLVD # K9
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48202-2689
Practice Address - Country:US
Practice Address - Phone:248-756-0384
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-03
Last Update Date:2022-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program