Provider Demographics
NPI:1295108090
Name:MIX, ETHAN (DPT)
Entity type:Individual
Prefix:
First Name:ETHAN
Middle Name:
Last Name:MIX
Suffix:
Gender:M
Credentials: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 60447
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-0447
Mailing Address - Country:US
Mailing Address - Phone:704-510-8000
Mailing Address - Fax:704-510-8006
Practice Address - Street 1:445 S KINGS DR
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28204-3041
Practice Address - Country:US
Practice Address - Phone:704-384-1737
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-11-03
Last Update Date:2021-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY039525-1225100000X
NCP17497225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist