Provider Demographics
NPI:1811486459
Name:SKOG, ETHAN LEE (DC)
Entity type:Individual
Prefix:DR
First Name:ETHAN
Middle Name:LEE
Last Name:SKOG
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4900 HIGHWAY 169 N STE 301
Mailing Address - Street 2:
Mailing Address - City:NEW HOPE
Mailing Address - State:MN
Mailing Address - Zip Code:55428-4019
Mailing Address - Country:US
Mailing Address - Phone:763-496-7871
Mailing Address - Fax:
Practice Address - Street 1:4900 HIGHWAY 169 N STE 301
Practice Address - Street 2:
Practice Address - City:NEW HOPE
Practice Address - State:MN
Practice Address - Zip Code:55428-4019
Practice Address - Country:US
Practice Address - Phone:763-496-7871
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-09
Last Update Date:2020-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN6473111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor