Provider Demographics
NPI:1407245558
Name:ETIENNE, JOSE R (PA-C)
Entity Type:Individual
Prefix:
First Name:JOSE
Middle Name:R
Last Name:ETIENNE
Suffix:
Gender:M
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 1:5555 GLENRIDGE CONNECTOR
Mailing Address - Street 2:STE 700
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30342-4758
Mailing Address - Country:US
Mailing Address - Phone:678-956-6531
Mailing Address - Fax:678-567-3570
Practice Address - Street 1:130-17 221 STREET
Practice Address - Street 2:
Practice Address - City:LAURELTON
Practice Address - State:NY
Practice Address - Zip Code:11413
Practice Address - Country:US
Practice Address - Phone:718-775-7765
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-01-13
Last Update Date:2016-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY018374363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant