Provider Demographics
NPI:1134849326
Name:SLABAUGH, ETHAN THOMAS (DNP)
Entity type:Individual
Prefix:
First Name:ETHAN
Middle Name:THOMAS
Last Name:SLABAUGH
Suffix:
Gender:
Credentials:DNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:82 WENDELL AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:PITTSFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01201-7066
Mailing Address - Country:US
Mailing Address - Phone:617-517-6340
Mailing Address - Fax:423-301-6604
Practice Address - Street 1:82 WENDELL AVE STE 100
Practice Address - Street 2:
Practice Address - City:PITTSFIELD
Practice Address - State:MA
Practice Address - Zip Code:01201-7066
Practice Address - Country:US
Practice Address - Phone:617-517-6340
Practice Address - Fax:423-301-6604
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-30
Last Update Date:2025-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN2361626363LF0000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily