Provider Demographics
NPI:1407245558
Name:ETIENNE, JOSE R (PA-C)
Entity type:Individual
Prefix:
First Name:JOSE
Middle Name:R
Last Name:ETIENNE
Suffix:
Gender:M
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 1:4057 RILEY FUZZEL RD STE 1100B
Mailing Address - Street 2:
Mailing Address - City:SPRING
Mailing Address - State:TX
Mailing Address - Zip Code:77386-4632
Mailing Address - Country:US
Mailing Address - Phone:281-907-4863
Mailing Address - Fax:
Practice Address - Street 1:4057 RILEY FUZZEL RD STE 1100B
Practice Address - Street 2:
Practice Address - City:SPRING
Practice Address - State:TX
Practice Address - Zip Code:77386-4632
Practice Address - Country:US
Practice Address - Phone:281-907-4863
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-01-13
Last Update Date:2024-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY018374363A00000X
TXPA10643363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant