Healthcare Provider Details

I. General information

NPI: 1508595729
Provider Name (Legal Business Name): ETHAN LEROY SNYDER PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/06/2022
Last Update Date: 01/06/2024
Certification Date: 01/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

585 N MOUNTAIN AVE STE A
UPLAND CA
91786-8516
US

IV. Provider business mailing address

101 E REDLANDS BLVD STE 284
REDLANDS CA
92373-4721
US

V. Phone/Fax

Practice location:
  • Phone: 909-608-7546
  • Fax:
Mailing address:
  • Phone: 909-312-7380
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA63622
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: