Provider Demographics
NPI:1881299436
Name:HALL, ETHAN WAYNE
Entity type:Individual
Prefix:
First Name:ETHAN
Middle Name:WAYNE
Last Name:HALL
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 1:529 NEWPORT CT
Mailing Address - Street 2:
Mailing Address - City:BECKLEY
Mailing Address - State:WV
Mailing Address - Zip Code:25801-2177
Mailing Address - Country:US
Mailing Address - Phone:304-673-2931
Mailing Address - Fax:
Practice Address - Street 1:529 NEWPORT CT
Practice Address - Street 2:
Practice Address - City:BECKLEY
Practice Address - State:WV
Practice Address - Zip Code:25801-2177
Practice Address - Country:US
Practice Address - Phone:304-673-2931
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-02
Last Update Date:2023-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant