Provider Demographics
NPI:1235780883
Name:ETZKORN, ALYSSA JO (PA-C)
Entity Type:Individual
Prefix:
First Name:ALYSSA
Middle Name:JO
Last Name:ETZKORN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:102 VILLAGE DR
Mailing Address - Street 2:
Mailing Address - City:PIERRE
Mailing Address - State:SD
Mailing Address - Zip Code:57501-2886
Mailing Address - Country:US
Mailing Address - Phone:605-222-7312
Mailing Address - Fax:
Practice Address - Street 1:100 MAC LN
Practice Address - Street 2:
Practice Address - City:PIERRE
Practice Address - State:SD
Practice Address - Zip Code:57501-3391
Practice Address - Country:US
Practice Address - Phone:605-945-5277
Practice Address - Fax:605-945-5389
Is Sole Proprietor?:No
Enumeration Date:2019-09-25
Last Update Date:2023-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD1218363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant