Provider Demographics
NPI:1740801745
Name:VIRGIN, ETHAN KYLE (RN)
Entity Type:Individual
Prefix:MR
First Name:ETHAN
Middle Name:KYLE
Last Name:VIRGIN
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:PO BOX 754
Mailing Address - Street 2:
Mailing Address - City:SANDY HOOK
Mailing Address - State:KY
Mailing Address - Zip Code:41171-0754
Mailing Address - Country:US
Mailing Address - Phone:606-465-4886
Mailing Address - Fax:
Practice Address - Street 1:2900 1ST AVE
Practice Address - Street 2:
Practice Address - City:HUNTINGTON
Practice Address - State:WV
Practice Address - Zip Code:25702-1241
Practice Address - Country:US
Practice Address - Phone:304-526-1234
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-30
Last Update Date:2020-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1145109163W00000X
WV107258367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse