Provider Demographics
NPI:1477706968
Name:NETTLES, EDNA BETH (PA-C)
Entity Type:Individual
Prefix:
First Name:EDNA
Middle Name:BETH
Last Name:NETTLES
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 1:2706 HESSMER AVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:METAIRIE
Mailing Address - State:LA
Mailing Address - Zip Code:70002-7041
Mailing Address - Country:US
Mailing Address - Phone:504-754-2334
Mailing Address - Fax:504-324-2078
Practice Address - Street 1:2706 HESSMER AVE
Practice Address - Street 2:SUITE A
Practice Address - City:METAIRIE
Practice Address - State:LA
Practice Address - Zip Code:70002-7041
Practice Address - Country:US
Practice Address - Phone:504-754-2334
Practice Address - Fax:504-324-2078
Is Sole Proprietor?:No
Enumeration Date:2008-10-28
Last Update Date:2015-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNPA1680363A00000X
LAPA200705363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1509761Medicaid
TN1505839Medicaid
TN4211276OtherBCBS TN
TN4211276OtherBCBS TN
TN1505839Medicaid
TN36653181Medicare PIN