Provider Demographics
NPI:1326588732
Name:VAN ETTEN, ELISE NICOLE (PA)
Entity Type:Individual
Prefix:
First Name:ELISE
Middle Name:NICOLE
Last Name:VAN ETTEN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:ELISE
Other - Middle Name:NICOLE
Other - Last Name:SHELLENBERGER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:13123 E 16TH AVE # 323
Mailing Address - Street 2:ANSCHUTZ MEDICAL CAMPUS
Mailing Address - City:AURORA
Mailing Address - State:CO
Mailing Address - Zip Code:80045-7106
Mailing Address - Country:US
Mailing Address - Phone:703-328-2787
Mailing Address - Fax:
Practice Address - Street 1:13123 E 16TH AVE # 323
Practice Address - Street 2:ANSCHUTZ MEDICAL CAMPUS
Practice Address - City:AURORA
Practice Address - State:CO
Practice Address - Zip Code:80045-7106
Practice Address - Country:US
Practice Address - Phone:703-328-2787
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-03
Last Update Date:2019-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0004919363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical