Provider Demographics
NPI:1669460440
Name:ETTER, BOYD A (PT, DIP MDT, OCS)
Entity Type:Individual
Prefix:
First Name:BOYD
Middle Name:A
Last Name:ETTER
Suffix:
Gender:M
Credentials:PT, DIP MDT, OCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10775 DOUBLE R BLVD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89521
Mailing Address - Country:US
Mailing Address - Phone:775-853-7475
Mailing Address - Fax:775-853-2013
Practice Address - Street 1:555 N ARLINGTON AVE
Practice Address - Street 2:
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89503-4723
Practice Address - Country:US
Practice Address - Phone:775-788-5242
Practice Address - Fax:775-786-6942
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-06
Last Update Date:2012-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV869225100000X
225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV3416042Medicaid
NV3416042Medicaid
NV35897Medicare ID - Type Unspecified