Provider Demographics
NPI:1710316732
Name:WARNER, ETHAN B (PT, DPT)
Entity Type:Individual
Prefix:
First Name:ETHAN
Middle Name:B
Last Name:WARNER
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6355 WALKER LN
Mailing Address - Street 2:SUITE #404
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22310-3245
Mailing Address - Country:US
Mailing Address - Phone:703-797-6900
Mailing Address - Fax:
Practice Address - Street 1:6355 WALKER LN
Practice Address - Street 2:SUITE #404
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22310-3245
Practice Address - Country:US
Practice Address - Phone:703-797-6900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-11-12
Last Update Date:2013-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305208421225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist