Provider Demographics
NPI:1275629966
Name:ETTIEN, JAMES T
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:T
Last Name:ETTIEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:397 WALLACE RD
Mailing Address - Street 2:SUITE C414
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37211-8022
Mailing Address - Country:US
Mailing Address - Phone:615-781-9499
Mailing Address - Fax:615-781-3882
Practice Address - Street 1:397 WALLACE RD
Practice Address - Street 2:SUITE C414
Practice Address - City:NASHVILLE
Practice Address - State:TN
Practice Address - Zip Code:37211-8022
Practice Address - Country:US
Practice Address - Phone:615-781-9499
Practice Address - Fax:615-781-3882
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2019-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN41425208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3833106Medicaid
TND45296Medicare UPIN
TN3833106Medicaid
TNP00432657Medicare PIN
TN622097Medicare ID - Type Unspecified