Provider Demographics
NPI:1841648870
Name:PCOLAR, ETHAN T (ATC)
Entity type:Individual
Prefix:
First Name:ETHAN
Middle Name:T
Last Name:PCOLAR
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:945 FOOTHILL DR
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95123-2628
Mailing Address - Country:US
Mailing Address - Phone:845-518-4259
Mailing Address - Fax:
Practice Address - Street 1:4805 WESTMONT AVE
Practice Address - Street 2:
Practice Address - City:CAMPBELL
Practice Address - State:CA
Practice Address - Zip Code:95008-5725
Practice Address - Country:US
Practice Address - Phone:845-518-4259
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-31
Last Update Date:2016-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY20000215312255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer