Provider Demographics
NPI:1497193585
Name:ROBERTS, ETHAN
Entity Type:Individual
Prefix:
First Name:ETHAN
Middle Name:
Last Name:ROBERTS
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 1:722 NORVELL ST
Mailing Address - Street 2:
Mailing Address - City:EL CERRITO
Mailing Address - State:CA
Mailing Address - Zip Code:94530-3246
Mailing Address - Country:US
Mailing Address - Phone:510-647-9836
Mailing Address - Fax:
Practice Address - Street 1:722 NORVELL ST
Practice Address - Street 2:
Practice Address - City:EL CERRITO
Practice Address - State:CA
Practice Address - Zip Code:94530-3246
Practice Address - Country:US
Practice Address - Phone:510-647-9836
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-11
Last Update Date:2022-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program