Healthcare Provider Details

I. General information

NPI: 1750124442
Provider Name (Legal Business Name): GRACE JEAN ETWAROO PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/18/2024
Last Update Date: 08/12/2024
Certification Date: 08/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1044 STATE ST
SCHENECTADY NY
12307-1508
US

IV. Provider business mailing address

1044 STATE ST
SCHENECTADY NY
12307-1508
US

V. Phone/Fax

Practice location:
  • Phone: 518-370-1441
  • Fax:
Mailing address:
  • Phone: 518-370-1441
  • Fax: 518-395-9431

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: