Provider Demographics
NPI:1164663589
Name:NAYBACK, ETHAN ANDREW (AT-C)
Entity Type:Individual
Prefix:MR
First Name:ETHAN
Middle Name:ANDREW
Last Name:NAYBACK
Suffix:
Gender:M
Credentials:AT-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3905 LEONARD ST
Mailing Address - Street 2:
Mailing Address - City:MARNE
Mailing Address - State:MI
Mailing Address - Zip Code:49435-9721
Mailing Address - Country:US
Mailing Address - Phone:616-558-2715
Mailing Address - Fax:
Practice Address - Street 1:3905 LEONARD ST
Practice Address - Street 2:
Practice Address - City:MARNE
Practice Address - State:MI
Practice Address - Zip Code:49435-9721
Practice Address - Country:US
Practice Address - Phone:616-558-2715
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-03-14
Last Update Date:2022-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer