Provider Demographics
NPI:1609283944
Name:APP, ETHAN (MPT)
Entity Type:Individual
Prefix:MR
First Name:ETHAN
Middle Name:
Last Name:APP
Suffix:
Gender:M
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1421 RIVERSIDE AVE
Mailing Address - Street 2:
Mailing Address - City:PASO ROBLES
Mailing Address - State:CA
Mailing Address - Zip Code:93446-1730
Mailing Address - Country:US
Mailing Address - Phone:805-462-1110
Mailing Address - Fax:805-462-0660
Practice Address - Street 1:3218 EL CAMINO REAL
Practice Address - Street 2:
Practice Address - City:ATASCADERO
Practice Address - State:CA
Practice Address - Zip Code:93422-2500
Practice Address - Country:US
Practice Address - Phone:805-462-1110
Practice Address - Fax:805-462-0660
Is Sole Proprietor?:No
Enumeration Date:2014-07-18
Last Update Date:2020-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225100000X
CA41365225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist