Healthcare Provider Details

I. General information

NPI: 1942752944
Provider Name (Legal Business Name): ETHAN YODER PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/26/2016
Last Update Date: 08/21/2020
Certification Date: 08/21/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1540 CITRUS MEDICAL CT
OCOEE FL
34761-4547
US

IV. Provider business mailing address

1540 CITRUS MEDICAL CT
OCOEE FL
34761-4547
US

V. Phone/Fax

Practice location:
  • Phone: 407-602-7168
  • Fax:
Mailing address:
  • Phone: 407-602-7168
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9109969
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: