Provider Demographics
NPI:1912547365
Name:ETHERTON, THOMAS LEE (NP-C)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:LEE
Last Name:ETHERTON
Suffix:
Gender:M
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2610 YELM HWY SE
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98501-4826
Mailing Address - Country:US
Mailing Address - Phone:360-915-9389
Mailing Address - Fax:
Practice Address - Street 1:2610 YELM HWY SE
Practice Address - Street 2:
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98501-4826
Practice Address - Country:US
Practice Address - Phone:360-915-9389
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-14
Last Update Date:2021-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP61034795363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary CareGroup - Single Specialty