Provider Demographics
NPI:1881464519
Name:AGUILAR BRAVO, ETHAN ADAM
Entity type:Individual
Prefix:
First Name:ETHAN
Middle Name:ADAM
Last Name:AGUILAR BRAVO
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 1:40916 ROAD 56
Mailing Address - Street 2:
Mailing Address - City:REEDLEY
Mailing Address - State:CA
Mailing Address - Zip Code:93654-9133
Mailing Address - Country:US
Mailing Address - Phone:559-740-2890
Mailing Address - Fax:
Practice Address - Street 1:1075 E BETTERAVIA RD STE 201
Practice Address - Street 2:
Practice Address - City:SANTA MARIA
Practice Address - State:CA
Practice Address - Zip Code:93454-7023
Practice Address - Country:US
Practice Address - Phone:805-621-7714
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-04
Last Update Date:2024-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA42870227900000X
CA363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No227900000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRespiratory Therapist, Registered