Provider Demographics
NPI:1750710315
Name:ETIENNE, DOMINIQUE (PA-C)
Entity type:Individual
Prefix:
First Name:DOMINIQUE
Middle Name:
Last Name:ETIENNE
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 1:1603 E WADSWORTH AVE
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19150-1019
Mailing Address - Country:US
Mailing Address - Phone:215-242-2439
Mailing Address - Fax:215-242-2596
Practice Address - Street 1:1603 E WADSWORTH AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19150-1019
Practice Address - Country:US
Practice Address - Phone:215-242-2439
Practice Address - Fax:215-242-2596
Is Sole Proprietor?:No
Enumeration Date:2013-11-04
Last Update Date:2015-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA056503363A00000X
NJ25MP00317800363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant