Provider Demographics
NPI:1801314315
Name:ETCHEVERRIA, EDEN DESIREE (PA)
Entity type:Individual
Prefix:
First Name:EDEN
Middle Name:DESIREE
Last Name:ETCHEVERRIA
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1115 WEBER ST
Mailing Address - Street 2:
Mailing Address - City:FRANKLIN
Mailing Address - State:LA
Mailing Address - Zip Code:70538-4124
Mailing Address - Country:US
Mailing Address - Phone:337-828-2550
Mailing Address - Fax:337-355-2332
Practice Address - Street 1:1115 WEBER ST
Practice Address - Street 2:
Practice Address - City:FRANKLIN
Practice Address - State:LA
Practice Address - Zip Code:70538-4124
Practice Address - Country:US
Practice Address - Phone:337-828-2550
Practice Address - Fax:337-355-2332
Is Sole Proprietor?:No
Enumeration Date:2017-09-05
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA307132363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2457185Medicaid