Provider Demographics
NPI:1679233498
Name:WALN, ETHAN (RN)
Entity Type:Individual
Prefix:
First Name:ETHAN
Middle Name:
Last Name:WALN
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1043 NE 77TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97213-6868
Mailing Address - Country:US
Mailing Address - Phone:541-962-5221
Mailing Address - Fax:
Practice Address - Street 1:890 OAK ST SE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97301-3905
Practice Address - Country:US
Practice Address - Phone:503-814-5110
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-20
Last Update Date:2021-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program