Healthcare Provider Details

I. General information

NPI: 1922615814
Provider Name (Legal Business Name): ETHAN ROBERT CURTIS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/25/2020
Last Update Date: 08/27/2026
Certification Date: 08/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

29 BISHOP ST
ROYAL OAKS CA
95076-5266
US

IV. Provider business mailing address

4620 PACES FERRY DR
DURHAM NC
27712-2196
US

V. Phone/Fax

Practice location:
  • Phone: 831-728-2505
  • Fax:
Mailing address:
  • Phone: 315-200-6266
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number62659
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: