Healthcare Provider Details

I. General information

NPI: 1801314315
Provider Name (Legal Business Name): EDEN DESIREE ETCHEVERRIA PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/05/2017
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1115 WEBER ST
FRANKLIN LA
70538-4124
US

IV. Provider business mailing address

1115 WEBER ST
FRANKLIN LA
70538-4124
US

V. Phone/Fax

Practice location:
  • Phone: 337-828-2550
  • Fax: 337-355-2332
Mailing address:
  • Phone: 337-828-2550
  • Fax: 337-355-2332

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number307132
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: