Provider Demographics
NPI:1477572345
Name:ETTER, THOMAS MATTHEW (DC)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:MATTHEW
Last Name:ETTER
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:TOM
Other - Middle Name:M
Other - Last Name:ETTER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DC
Mailing Address - Street 1:PO BOX 107
Mailing Address - Street 2:
Mailing Address - City:PONCA
Mailing Address - State:NE
Mailing Address - Zip Code:68770-0107
Mailing Address - Country:US
Mailing Address - Phone:402-755-4111
Mailing Address - Fax:913-568-8510
Practice Address - Street 1:111 N UNION ST # 107
Practice Address - Street 2:
Practice Address - City:PONCA
Practice Address - State:NE
Practice Address - Zip Code:68770-7297
Practice Address - Country:US
Practice Address - Phone:402-755-4111
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-19
Last Update Date:2014-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS4640111N00000X
NE1185111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS000A382Medicare UPIN