Provider Demographics
NPI:1063422343
Name:ETZELL, PAUL S (MD)
Entity type:Individual
Prefix:
First Name:PAUL
Middle Name:S
Last Name:ETZELL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:712 SOUTH CASCADE STREET
Mailing Address - Street 2:
Mailing Address - City:FERGUS FALLS
Mailing Address - State:MN
Mailing Address - Zip Code:56537-2813
Mailing Address - Country:US
Mailing Address - Phone:218-736-8000
Mailing Address - Fax:218-736-8757
Practice Address - Street 1:712 SOUTH CASCADE STREET
Practice Address - Street 2:
Practice Address - City:FERGUS FALLS
Practice Address - State:MN
Practice Address - Zip Code:56537-2813
Practice Address - Country:US
Practice Address - Phone:218-736-8000
Practice Address - Fax:218-736-8757
Is Sole Proprietor?:No
Enumeration Date:2006-08-09
Last Update Date:2010-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN17327207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE41091744413Medicaid
ND12234Medicaid
MN36-00025OtherMEDICA NUMBER
MNHP10403OtherHEALTHPARTNERS NUMBER
MN41-0917444OtherONE HEALTH PLAN
MN0896037OtherPREFERRED ONE NUMBER
MN123436OtherU-CARE NUMBER
MN129768600Medicaid
MN11Q47ETOtherBCBS NUMBER
MNHP10403OtherHEALTHPARTNERS NUMBER
MN11Q47ETOtherBCBS NUMBER
NE41091744413Medicaid