Healthcare Provider Details

I. General information

NPI: 1962965681
Provider Name (Legal Business Name): ETHAN DANIEL MONHOLLON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/09/2019
Last Update Date: 06/29/2022
Certification Date: 06/29/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

701 10TH ST SE
CEDAR RAPIDS IA
52403-1251
US

IV. Provider business mailing address

122 S LINN ST
IOWA CITY IA
52240-1802
US

V. Phone/Fax

Practice location:
  • Phone: 319-398-6011
  • Fax:
Mailing address:
  • Phone: 319-338-9222
  • Fax: 319-338-7250

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number63675
License Number StateTN
# 3
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberMD-49479
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: