Provider Demographics
NPI:1518953363
Name:ETENBURN, WILLIAM (OPA-C)
Entity Type:Individual
Prefix:MR
First Name:WILLIAM
Middle Name:
Last Name:ETENBURN
Suffix:
Gender:M
Credentials:OPA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:627 25 1/2 RD
Mailing Address - Street 2:
Mailing Address - City:GRAND JUNCTION
Mailing Address - State:CO
Mailing Address - Zip Code:81505-6401
Mailing Address - Country:US
Mailing Address - Phone:970-242-3535
Mailing Address - Fax:
Practice Address - Street 1:627 25 1/2 RD
Practice Address - Street 2:
Practice Address - City:GRAND JUNCTION
Practice Address - State:CO
Practice Address - Zip Code:81505-6401
Practice Address - Country:US
Practice Address - Phone:970-242-3535
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-26
Last Update Date:2007-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL3363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical