Provider Demographics
NPI:1053820282
Name:MERROW, ETHAN ZACHARIAH
Entity Type:Individual
Prefix:
First Name:ETHAN
Middle Name:ZACHARIAH
Last Name:MERROW
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1701 MULBERRY LAKE DR
Mailing Address - Street 2:
Mailing Address - City:DACULA
Mailing Address - State:GA
Mailing Address - Zip Code:30019-4642
Mailing Address - Country:US
Mailing Address - Phone:770-712-4910
Mailing Address - Fax:
Practice Address - Street 1:1701 MULBERRY LAKE DRIVE
Practice Address - Street 2:
Practice Address - City:DACULA
Practice Address - State:GA
Practice Address - Zip Code:30019
Practice Address - Country:US
Practice Address - Phone:770-712-4910
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-20
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
390200000XOtherCHRIS LINKER ATC LAT