Provider Demographics
NPI:1134098833
Name:DOE, ETHAN
Entity type:Individual
Prefix:
First Name:ETHAN
Middle Name:
Last Name:DOE
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 1:11823 RIDGE PKWY APT 817
Mailing Address - Street 2:
Mailing Address - City:BROOMFIELD
Mailing Address - State:CO
Mailing Address - Zip Code:80021-5099
Mailing Address - Country:US
Mailing Address - Phone:708-941-7406
Mailing Address - Fax:
Practice Address - Street 1:3180 AIRPORT RD
Practice Address - Street 2:
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80301-2208
Practice Address - Country:US
Practice Address - Phone:303-447-1665
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-10-31
Last Update Date:2025-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CORN.1675791163WC0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC0400XNursing Service ProvidersRegistered NurseCase Management