Provider Demographics
NPI:1578815304
Name:ETTINGER, GENA MARIE (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:GENA
Middle Name:MARIE
Last Name:ETTINGER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MISS
Other - First Name:GENA
Other - Middle Name:MARIE
Other - Last Name:COX
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:PO BOX 35629
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75235-0629
Mailing Address - Country:US
Mailing Address - Phone:214-424-2213
Mailing Address - Fax:214-231-2159
Practice Address - Street 1:505 S NOLEN DR STE B
Practice Address - Street 2:
Practice Address - City:SOUTHLAKE
Practice Address - State:TX
Practice Address - Zip Code:76092-9167
Practice Address - Country:US
Practice Address - Phone:817-410-7777
Practice Address - Fax:817-410-9906
Is Sole Proprietor?:No
Enumeration Date:2012-10-03
Last Update Date:2021-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA08076363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX341037YLLYMedicare PIN