Provider Demographics
NPI:1134652977
Name:KNOWLTON, ETHAN JAMES
Entity Type:Individual
Prefix:
First Name:ETHAN
Middle Name:JAMES
Last Name:KNOWLTON
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 1:1010 CARONDELET DR STE 301
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64114-4823
Mailing Address - Country:US
Mailing Address - Phone:816-943-1111
Mailing Address - Fax:
Practice Address - Street 1:1010 CARONDELET DR STE 301
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64114-4823
Practice Address - Country:US
Practice Address - Phone:816-943-1111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-08
Last Update Date:2021-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILK54321091039213E00000X
390200000X
MO2020014411213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program