Provider Demographics
NPI:1427605682
Name:MIDYETTE, ELIZABETH ABAGAIL (PA-C)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:ABAGAIL
Last Name:MIDYETTE
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:PO BOX 66156
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70896-6156
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3917 WEST RD STE A
Practice Address - Street 2:
Practice Address - City:LOS ALAMOS
Practice Address - State:NM
Practice Address - Zip Code:87544-2292
Practice Address - Country:US
Practice Address - Phone:505-661-8900
Practice Address - Fax:505-661-8916
Is Sole Proprietor?:No
Enumeration Date:2019-08-22
Last Update Date:2023-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA324685363A00000X
NMPA2023-0235363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMPA2023-0235OtherNM MEDICAL BOARD