Basic Information
| Provider Information | |||||||||
| NPI: | 1063422343 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ETZELL | ||||||||
| FirstName: | PAUL | ||||||||
| MiddleName: | S | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 712 SOUTH CASCADE STREET | ||||||||
| Address2: | |||||||||
| City: | FERGUS FALLS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 565372813 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2187368000 | ||||||||
| FaxNumber: | 2187368757 | ||||||||
| Practice Location | |||||||||
| Address1: | 712 SOUTH CASCADE STREET | ||||||||
| Address2: | |||||||||
| City: | FERGUS FALLS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 565372813 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2187368000 | ||||||||
| FaxNumber: | 2187368757 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/09/2006 | ||||||||
| LastUpdateDate: | 07/09/2010 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RH0003X | 17327 | MN | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology |
ID Information
| ID | Type | State | Issuer | Description | 41091744413 | 05 | NE | MEDICAID | 12234 | 05 | ND | MEDICAID | 36-00025 | 01 | MN | MEDICA NUMBER | OTHER | HP10403 | 01 | MN | HEALTHPARTNERS NUMBER | OTHER | 41-0917444 | 01 | MN | ONE HEALTH PLAN | OTHER | 0896037 | 01 | MN | PREFERRED ONE NUMBER | OTHER | 123436 | 01 | MN | U-CARE NUMBER | OTHER | 129768600 | 05 | MN | MEDICAID | 11Q47ET | 01 | MN | BCBS NUMBER | OTHER |