Provider Demographics
NPI:1942065560
Name:VAN SICKLE, ETHAN HUNTER
Entity Type:Individual
Prefix:
First Name:ETHAN
Middle Name:HUNTER
Last Name:VAN SICKLE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11155 E LINVALE DR
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:CO
Mailing Address - Zip Code:80014-3090
Mailing Address - Country:US
Mailing Address - Phone:720-556-8056
Mailing Address - Fax:
Practice Address - Street 1:11155 E LINVALE DR
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:CO
Practice Address - Zip Code:80014-3090
Practice Address - Country:US
Practice Address - Phone:720-556-8056
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-14
Last Update Date:2024-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program