Provider Demographics
NPI:1578200580
Name:MOLES, ETHAN ARON (DMPNA, CRNA)
Entity Type:Individual
Prefix:
First Name:ETHAN
Middle Name:ARON
Last Name:MOLES
Suffix:
Gender:M
Credentials:DMPNA, CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1892 PATTERSON DR
Mailing Address - Street 2:
Mailing Address - City:ELKVIEW
Mailing Address - State:WV
Mailing Address - Zip Code:25071-7131
Mailing Address - Country:US
Mailing Address - Phone:304-941-3630
Mailing Address - Fax:
Practice Address - Street 1:4605 MACCORKLE AVE SW
Practice Address - Street 2:
Practice Address - City:SOUTH CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25309-1311
Practice Address - Country:US
Practice Address - Phone:304-766-3600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-19
Last Update Date:2022-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV85894163W00000X
WV112703367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse