Provider Demographics
NPI:1649023276
Name:TYREE, ETHAN S
Entity type:Individual
Prefix:
First Name:ETHAN
Middle Name:S
Last Name:TYREE
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 1:51 FORREST HILLS DR
Mailing Address - Street 2:
Mailing Address - City:VOORHEES
Mailing Address - State:NJ
Mailing Address - Zip Code:08043-3910
Mailing Address - Country:US
Mailing Address - Phone:609-864-2224
Mailing Address - Fax:
Practice Address - Street 1:1505 W SHERMAN AVE
Practice Address - Street 2:
Practice Address - City:VINELAND
Practice Address - State:NJ
Practice Address - Zip Code:08360-7059
Practice Address - Country:US
Practice Address - Phone:856-641-8000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-11
Last Update Date:2024-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program