Provider Demographics
NPI:1649913138
Name:FAN, ETHAN MATTHEW
Entity type:Individual
Prefix:
First Name:ETHAN
Middle Name:MATTHEW
Last Name:FAN
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 1:1140 PEACOCK BLVD
Mailing Address - Street 2:
Mailing Address - City:CARROLLTON
Mailing Address - State:TX
Mailing Address - Zip Code:75007-2943
Mailing Address - Country:US
Mailing Address - Phone:469-471-4848
Mailing Address - Fax:
Practice Address - Street 1:8200 WALNUT HILL LN
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75231-4402
Practice Address - Country:US
Practice Address - Phone:214-345-6176
Practice Address - Fax:214-345-5167
Is Sole Proprietor?:No
Enumeration Date:2022-04-14
Last Update Date:2022-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program