Provider Demographics
NPI:1669101150
Name:GARRIS, ETHAN WAYNE (PA-C)
Entity type:Individual
Prefix:MR
First Name:ETHAN
Middle Name:WAYNE
Last Name:GARRIS
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2919 ROANOKE AVE
Mailing Address - Street 2:
Mailing Address - City:NEW BERN
Mailing Address - State:NC
Mailing Address - Zip Code:28562-2543
Mailing Address - Country:US
Mailing Address - Phone:252-497-6769
Mailing Address - Fax:
Practice Address - Street 1:1135 CARTHAGE ST
Practice Address - Street 2:
Practice Address - City:SANFORD
Practice Address - State:NC
Practice Address - Zip Code:27330-4162
Practice Address - Country:US
Practice Address - Phone:919-774-2100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-09
Last Update Date:2022-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant