Provider Demographics
NPI:1740064930
Name:CHYNOWETH, WILLIAM ETHAN
Entity type:Individual
Prefix:
First Name:WILLIAM
Middle Name:ETHAN
Last Name:CHYNOWETH
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 1:8440 N FAWN LAKE RD NE
Mailing Address - Street 2:
Mailing Address - City:STACY
Mailing Address - State:MN
Mailing Address - Zip Code:55079-3204
Mailing Address - Country:US
Mailing Address - Phone:505-331-9876
Mailing Address - Fax:
Practice Address - Street 1:2235 DOUGLAS BLVD STE 520
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:CA
Practice Address - Zip Code:95661-4266
Practice Address - Country:US
Practice Address - Phone:191-677-2719
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-21
Last Update Date:2023-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMPT6146225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist