Provider Demographics
NPI:1710676812
Name:BROWN, ETHAN GABRIEL (PTA)
Entity Type:Individual
Prefix:
First Name:ETHAN
Middle Name:GABRIEL
Last Name:BROWN
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4150 CULP RIDGE TRL APT 308
Mailing Address - Street 2:
Mailing Address - City:INDIAN LAND
Mailing Address - State:SC
Mailing Address - Zip Code:29707-6180
Mailing Address - Country:US
Mailing Address - Phone:803-847-2657
Mailing Address - Fax:
Practice Address - Street 1:105 WAXHAW PROFESSIONAL PARK DR STE B
Practice Address - Street 2:
Practice Address - City:WAXHAW
Practice Address - State:NC
Practice Address - Zip Code:28173-5018
Practice Address - Country:US
Practice Address - Phone:704-459-4013
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-04
Last Update Date:2023-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA8052225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant