Healthcare Provider Details

I. General information

NPI: 1720734171
Provider Name (Legal Business Name): ETHAN RICHTER PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/24/2022
Last Update Date: 06/10/2026
Certification Date: 06/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

27650 FERRY RD STE 100
WARRENVILLE IL
60555-3846
US

IV. Provider business mailing address

27650 FERRY RD STE 100
WARRENVILLE IL
60555-3846
US

V. Phone/Fax

Practice location:
  • Phone: 630-225-2663
  • Fax: 630-225-2399
Mailing address:
  • Phone: 630-225-2663
  • Fax: 630-225-2399

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number50.007619RX
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number085011609
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: