Provider Demographics
NPI:1245574599
Name:STANG, ETHAN (PT)
Entity Type:Individual
Prefix:MR
First Name:ETHAN
Middle Name:
Last Name:STANG
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4600 BRAMBLETON AVE
Mailing Address - Street 2:STE B
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24018-3437
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4600 BRAMBLETON AVE
Practice Address - Street 2:STE B
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24018-3437
Practice Address - Country:US
Practice Address - Phone:540-774-0729
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-26
Last Update Date:2016-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP14016225100000X
VA2305207746225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist