Provider Demographics
NPI:1972211217
Name:WHALEY, ETHAN ALEXANDER (PT, DPT)
Entity Type:Individual
Prefix:
First Name:ETHAN
Middle Name:ALEXANDER
Last Name:WHALEY
Suffix:
Gender:M
Credentials:PT, DPT
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 1393
Mailing Address - Street 2:
Mailing Address - City:GOLIAD
Mailing Address - State:TX
Mailing Address - Zip Code:77963-1393
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:20818 GATHERING OAK STE 106
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78260-3105
Practice Address - Country:US
Practice Address - Phone:210-858-5006
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-07
Last Update Date:2022-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1369736225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist