Provider Demographics
NPI:1821619875
Name:ERNST, EDWARD THOMAS JR (PTA)
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:THOMAS
Last Name:ERNST
Suffix:JR
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 1:3909 BAYSIDE WAY APT 201
Mailing Address - Street 2:
Mailing Address - City:MANHATTAN
Mailing Address - State:KS
Mailing Address - Zip Code:66502-7259
Mailing Address - Country:US
Mailing Address - Phone:909-576-9180
Mailing Address - Fax:
Practice Address - Street 1:2121 MEADOWLARK RD
Practice Address - Street 2:
Practice Address - City:MANHATTAN
Practice Address - State:KS
Practice Address - Zip Code:66502-4521
Practice Address - Country:US
Practice Address - Phone:909-576-9180
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-30
Last Update Date:2020-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVA-1181225200000X
KS14-03677225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant