Provider Demographics
NPI:1841636115
Name:TAYLOR, ETHAN WADE
Entity type:Individual
Prefix:
First Name:ETHAN
Middle Name:WADE
Last Name:TAYLOR
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 1:1350 S MULDROW ST
Mailing Address - Street 2:
Mailing Address - City:TISHOMINGO
Mailing Address - State:OK
Mailing Address - Zip Code:73460-3278
Mailing Address - Country:US
Mailing Address - Phone:830-928-6990
Mailing Address - Fax:
Practice Address - Street 1:1350 S MULDROW ST
Practice Address - Street 2:
Practice Address - City:TISHOMINGO
Practice Address - State:OK
Practice Address - Zip Code:73460-3278
Practice Address - Country:US
Practice Address - Phone:830-928-6990
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-14
Last Update Date:2013-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator