Healthcare Provider Details

I. General information

NPI: 1538834619
Provider Name (Legal Business Name): ETHAN IRVIN PHYSICIAN ASSISTANT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/11/2021
Last Update Date: 07/28/2023
Certification Date: 07/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

655 7TH ST BLDG 700
ROBINS AFB GA
31098-2227
US

IV. Provider business mailing address

2803 MEDICAL CAMPUS DR
GOLDSBORO NC
27531
US

V. Phone/Fax

Practice location:
  • Phone: 478-497-7569
  • Fax:
Mailing address:
  • Phone: 919-722-1802
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171000000X
TaxonomyMilitary Health Care Provider
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: