Healthcare Provider Details

I. General information

NPI: 1932753100
Provider Name (Legal Business Name): ETHAN JOHN MYTINGER
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/26/2019
Last Update Date: 09/01/2022
Certification Date: 09/01/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1601 E 19TH AVE STE 5500
DENVER CO
80218-1291
US

IV. Provider business mailing address

3333 S BANNOCK ST STE 350
ENGLEWOOD CO
80110-2426
US

V. Phone/Fax

Practice location:
  • Phone: 303-777-7112
  • Fax: 303-722-7010
Mailing address:
  • Phone: 303-957-1310
  • Fax: 303-761-4252

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: