Provider Demographics
NPI:1013071117
Name:ETIENNE, ERNST (PA)
Entity Type:Individual
Prefix:
First Name:ERNST
Middle Name:
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 1:6565 FANNIN ST # B452
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77030-2703
Mailing Address - Country:US
Mailing Address - Phone:713-441-3620
Mailing Address - Fax:
Practice Address - Street 1:6565 FANNIN ST # B452
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77030-2703
Practice Address - Country:US
Practice Address - Phone:713-441-3620
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-21
Last Update Date:2022-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA03422363A00000X
FLPA9116247363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8Y1362OtherBLUE CROSS BLUE SHIELD
TXP01074751OtherRR MEDICARE
TX185010901Medicaid
TXP00387792OtherRAILROAD MEDICARE
TX185010902Medicaid
TX185010903Medicaid
TXP01254101OtherMEDICARE RR
TX484886ZSWDMedicare PIN
TX311818YMVQMedicare PIN
TX185010903Medicaid
TX8J3659Medicare PIN