Provider Demographics
NPI:1417314097
Name:JOERS, ETHAN
Entity Type:Individual
Prefix:
First Name:ETHAN
Middle Name:
Last Name:JOERS
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 1:5640 HIGHWAY Y
Mailing Address - Street 2:
Mailing Address - City:GERALD
Mailing Address - State:MO
Mailing Address - Zip Code:63037-1204
Mailing Address - Country:US
Mailing Address - Phone:314-609-1791
Mailing Address - Fax:
Practice Address - Street 1:5640 HIGHWAY Y
Practice Address - Street 2:
Practice Address - City:GERALD
Practice Address - State:MO
Practice Address - Zip Code:63037-1204
Practice Address - Country:US
Practice Address - Phone:314-609-1791
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-27
Last Update Date:2016-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2011040559225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant