Healthcare Provider Details

I. General information

NPI: 1497384168
Provider Name (Legal Business Name): GREGORY C ETIENNE PA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/05/2020
Last Update Date: 02/07/2025
Certification Date: 02/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

444 W OSBORN RD STE 200
PHOENIX AZ
85013-3817
US

IV. Provider business mailing address

4834 E BROADWAY BLVD
TUCSON AZ
85711-3610
US

V. Phone/Fax

Practice location:
  • Phone: 480-223-9314
  • Fax: 480-923-9155
Mailing address:
  • Phone: 480-223-9314
  • Fax: 480-923-9155

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number8320
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number154
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: