Provider Demographics
NPI:1679814651
Name:ETIENNE, ADLERE MICHEL
Entity Type:Individual
Prefix:MR
First Name:ADLERE
Middle Name:MICHEL
Last Name:ETIENNE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2055 VILLA SPRING CT
Mailing Address - Street 2:
Mailing Address - City:DACULA
Mailing Address - State:GA
Mailing Address - Zip Code:30019-2275
Mailing Address - Country:US
Mailing Address - Phone:757-606-4702
Mailing Address - Fax:
Practice Address - Street 1:2055 VILLA SPRING CT
Practice Address - Street 2:
Practice Address - City:DACULA
Practice Address - State:GA
Practice Address - Zip Code:30019-2275
Practice Address - Country:US
Practice Address - Phone:757-606-4702
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-03-15
Last Update Date:2018-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA4096363AS0400X
VA4096246ZC0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical