1275629966 NPI number — JAMES T ETTIEN

Table of content: FERNANDO ANDRE PALACIOS MD (NPI 1467296574)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1275629966 NPI number — JAMES T ETTIEN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ETTIEN
Provider First Name:
JAMES
Provider Middle Name:
T
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1275629966
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/24/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
397 WALLACE RD
Provider Second Line Business Mailing Address:
SUITE C414
Provider Business Mailing Address City Name:
NASHVILLE
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37211-8022
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
615-781-9499
Provider Business Mailing Address Fax Number:
615-781-3882

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
397 WALLACE RD
Provider Second Line Business Practice Location Address:
SUITE C414
Provider Business Practice Location Address City Name:
NASHVILLE
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37211-8022
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
615-781-9499
Provider Business Practice Location Address Fax Number:
615-781-3882
Provider Enumeration Date:
10/04/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 208600000X , with the licence number:  41425 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 3833106 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".




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