Provider Demographics
NPI:1225520455
Name:GINGRAS, ETHAN WILLIAM (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:
First Name:ETHAN
Middle Name:WILLIAM
Last Name:GINGRAS
Suffix:
Gender:M
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:798 DEVERSON DR
Mailing Address - Street 2:
Mailing Address - City:ROCKWALL
Mailing Address - State:TX
Mailing Address - Zip Code:75087-7172
Mailing Address - Country:US
Mailing Address - Phone:469-396-3360
Mailing Address - Fax:
Practice Address - Street 1:39769 I-20
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75237
Practice Address - Country:US
Practice Address - Phone:972-780-0802
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-04
Last Update Date:2023-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP137475363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily