Provider Demographics
NPI:1497384168
Name:ETIENNE, GREGORY C (PA)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:C
Last Name:ETIENNE
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5830 W THUNDERBIRD RD STE B8-1001
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85306-4654
Mailing Address - Country:US
Mailing Address - Phone:956-212-8416
Mailing Address - Fax:
Practice Address - Street 1:5331 S SUPERSTITION MOUNTAIN DR
Practice Address - Street 2:
Practice Address - City:GOLD CANYON
Practice Address - State:AZ
Practice Address - Zip Code:85118-1921
Practice Address - Country:US
Practice Address - Phone:480-413-0586
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-05
Last Update Date:2023-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR154363AM0700X
AZ8320363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical