Healthcare Provider Details

I. General information

NPI: 1881464519
Provider Name (Legal Business Name): ETHAN ADAM AGUILAR BRAVO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/04/2024
Last Update Date: 02/06/2024
Certification Date: 02/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1075 E BETTERAVIA RD STE 201
SANTA MARIA CA
93454-7023
US

IV. Provider business mailing address

40916 ROAD 56
REEDLEY CA
93654-9133
US

V. Phone/Fax

Practice location:
  • Phone: 805-621-7714
  • Fax:
Mailing address:
  • Phone: 559-740-2890
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code227900000X
TaxonomyRegistered Respiratory Therapist
License Number42870
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: