Provider Demographics
NPI:1821574625
Name:SETIAWAN, EDITHA C (PA-C)
Entity Type:Individual
Prefix:MS
First Name:EDITHA
Middle Name:C
Last Name:SETIAWAN
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 1:5309 L ST
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95819-3933
Mailing Address - Country:US
Mailing Address - Phone:530-220-0834
Mailing Address - Fax:
Practice Address - Street 1:2081 BRONZE STAR DR
Practice Address - Street 2:
Practice Address - City:WOODLAND
Practice Address - State:CA
Practice Address - Zip Code:95776-5423
Practice Address - Country:US
Practice Address - Phone:530-668-2600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-14
Last Update Date:2018-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA55606207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine