Provider Demographics
NPI:1417681255
Name:THAUT, ETHAN
Entity Type:Individual
Prefix:
First Name:ETHAN
Middle Name:
Last Name:THAUT
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 1:327 LAKESHORE DR
Mailing Address - Street 2:
Mailing Address - City:NORTH SIOUX CITY
Mailing Address - State:SD
Mailing Address - Zip Code:57049-4002
Mailing Address - Country:US
Mailing Address - Phone:307-337-6943
Mailing Address - Fax:
Practice Address - Street 1:801 5TH ST
Practice Address - Street 2:
Practice Address - City:SIOUX CITY
Practice Address - State:IA
Practice Address - Zip Code:51101-1326
Practice Address - Country:US
Practice Address - Phone:712-279-2010
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-15
Last Update Date:2022-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant