Provider Demographics
NPI:1043705395
Name:HUCKABEE, ETHAN MARK (DO)
Entity Type:Individual
Prefix:
First Name:ETHAN
Middle Name:MARK
Last Name:HUCKABEE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 850
Mailing Address - Street 2:
Mailing Address - City:PORT ANGELES
Mailing Address - State:WA
Mailing Address - Zip Code:98362-0146
Mailing Address - Country:US
Mailing Address - Phone:360-417-7111
Mailing Address - Fax:360-417-7342
Practice Address - Street 1:939 CAROLINE ST
Practice Address - Street 2:
Practice Address - City:PORT ANGELES
Practice Address - State:WA
Practice Address - Zip Code:98362-3997
Practice Address - Country:US
Practice Address - Phone:360-417-7000
Practice Address - Fax:360-565-9241
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-28
Last Update Date:2023-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036162411207P00000X
MI5101024216390200000X
MI5101026802207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program