Provider Demographics
NPI:1932753100
Name:MYTINGER, ETHAN JOHN
Entity Type:Individual
Prefix:
First Name:ETHAN
Middle Name:JOHN
Last Name:MYTINGER
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 1:3333 S BANNOCK ST STE 350
Mailing Address - Street 2:
Mailing Address - City:ENGLEWOOD
Mailing Address - State:CO
Mailing Address - Zip Code:80110-2426
Mailing Address - Country:US
Mailing Address - Phone:303-957-1310
Mailing Address - Fax:303-761-4252
Practice Address - Street 1:1601 E 19TH AVE STE 5500
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80218-1291
Practice Address - Country:US
Practice Address - Phone:303-777-7112
Practice Address - Fax:303-722-7010
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-26
Last Update Date:2022-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI6000000003748572Medicaid
CO9000181996Medicaid