Provider Demographics
NPI:1811963465
Name:ETIENNE, MINEKE E (MD)
Entity type:Individual
Prefix:
First Name:MINEKE
Middle Name:E
Last Name:ETIENNE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 MCCLELLAN ST
Mailing Address - Street 2:2 WEST
Mailing Address - City:SCHENECTADY
Mailing Address - State:NY
Mailing Address - Zip Code:12304-1009
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:624 MCCLELLAN STREET
Practice Address - Street 2:SUITE 101
Practice Address - City:SCHENECTADY
Practice Address - State:NY
Practice Address - Zip Code:12304-1020
Practice Address - Country:US
Practice Address - Phone:518-382-2260
Practice Address - Fax:518-347-5007
Is Sole Proprietor?:No
Enumeration Date:2006-02-24
Last Update Date:2015-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY262777207Q00000X
NY0022-11207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02634522Medicaid
NY53099AMedicare PIN
NY02634522Medicaid
NYL16175Medicare UPIN
NY331833Medicare Oscar/Certification
NYRA4286Medicare ID - Type Unspecified