Provider Demographics
NPI:1508595729
Name:SNYDER, ETHAN LEROY (PA)
Entity Type:Individual
Prefix:
First Name:ETHAN
Middle Name:LEROY
Last Name:SNYDER
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 E REDLANDS BLVD STE 284
Mailing Address - Street 2:
Mailing Address - City:REDLANDS
Mailing Address - State:CA
Mailing Address - Zip Code:92373-4721
Mailing Address - Country:US
Mailing Address - Phone:909-312-7380
Mailing Address - Fax:
Practice Address - Street 1:585 N MOUNTAIN AVE STE A
Practice Address - Street 2:
Practice Address - City:UPLAND
Practice Address - State:CA
Practice Address - Zip Code:91786-8516
Practice Address - Country:US
Practice Address - Phone:909-608-7546
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-06
Last Update Date:2024-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA63622363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant