Healthcare Provider Details

I. General information

NPI: 1427411065
Provider Name (Legal Business Name): THOMAS ETTER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/31/2016
Last Update Date: 01/31/2024
Certification Date: 01/31/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2006 S MAIN ST STE A
GOSHEN IN
46526-5232
US

IV. Provider business mailing address

2006 S MAIN ST STE A
GOSHEN IN
46526-5232
US

V. Phone/Fax

Practice location:
  • Phone: 574-535-9100
  • Fax: 574-535-1020
Mailing address:
  • Phone: 574-535-9100
  • Fax: 574-535-1020

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 State
# 2
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number01081405A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: