Provider Demographics
NPI:1376109520
Name:LAWLER, ETHAN
Entity type:Individual
Prefix:
First Name:ETHAN
Middle Name:
Last Name:LAWLER
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:PO BOX 232
Mailing Address - Street 2:
Mailing Address - City:LAKE NEBAGAMON
Mailing Address - State:WI
Mailing Address - Zip Code:54849-0232
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6883 S LAKE AVE
Practice Address - Street 2:
Practice Address - City:LAKE NEBAGAMON
Practice Address - State:WI
Practice Address - Zip Code:54849
Practice Address - Country:US
Practice Address - Phone:715-374-2856
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-14
Last Update Date:2019-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program