Provider Demographics
NPI:1184099988
Name:ETUE, MOLLY M (PA)
Entity type:Individual
Prefix:
First Name:MOLLY
Middle Name:M
Last Name:ETUE
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:MOLLY
Other - Middle Name:
Other - Last Name:SABOL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:11109 PARKVIEW PLAZA DR # 117
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46845-1701
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1990 HOSPITAL DR STE 110
Practice Address - Street 2:
Practice Address - City:SEDRO WOOLLEY
Practice Address - State:WA
Practice Address - Zip Code:98284-9315
Practice Address - Country:US
Practice Address - Phone:360-856-8830
Practice Address - Fax:360-714-2520
Is Sole Proprietor?:No
Enumeration Date:2015-12-04
Last Update Date:2024-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC5136363A00000X
WAPA61638047363A00000X
IN10002892A363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILPRESENCE100OtherMEDICARE PTAN