Dominique Etienne, PA-C

Primary specialty

Physician AssistantTaxonomy code 363A00000X

License

MA056503 Issued in PA

Practice address

1603 E Wadsworth Ave
Philadelphia, PA 19150-1019

Phone

(215) 242-2439

Fax

(215) 242-2596

NPI assigned

Nov 4, 2013

Last updated

Jun 5, 2015By the provider in NPPES

Sex

Female

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 2

Addresses

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Not enrolled

State licenses

Practice roles

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.

• Penrose Medical Center, Inc

  • Primary Care Clinic/Center
  • Philadelphia, PA
  • NPI 1417132929
  NPD (past)

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1383523200000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1433462400000",
    "number": "1750710315",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1603 E WADSWORTH AVE",
            "city": "PHILADELPHIA",
            "state": "PA",
            "postal_code": "191501019",
            "telephone_number": "215-242-2439",
            "fax_number": "215-242-2596"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1603 E WADSWORTH AVE",
            "city": "PHILADELPHIA",
            "state": "PA",
            "postal_code": "191501019",
            "telephone_number": "215-242-2439",
            "fax_number": "215-242-2596"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "ETIENNE",
        "first_name": "DOMINIQUE",
        "credential": "PA-C",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2013-11-04",
        "last_updated": "2015-06-05",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "363A00000X",
            "taxonomy_group": "",
            "desc": "Physician Assistant",
            "state": "PA",
            "license": "MA056503",
            "primary": true
        },
        {
            "code": "363A00000X",
            "taxonomy_group": "",
            "desc": "Physician Assistant",
            "state": "NJ",
            "license": "25MP00317800",
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Etana Care Inc
• Etapas Health Collective LLC
• Kambeze Banan Etemad, M.D.
• Ethel Lee Zachary Foundation
• Mark Etherington, MD
• Olivia Ann Etienne, MD
• Lisa Lucker Etkins, LCSW, OSW-C
• Abimbola Etou
• Beth Simone Etra, M.D.
• Jennifer B Ettenger

• Physician Assistant in Philadelphia, PA
• Providers in Philadelphia, PA by specialty
• Physician Assistant in Pennsylvania

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jun 5, 2015; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.