Healthcare Provider Details

I. General information

NPI: 1396802591
Provider Name (Legal Business Name): WILLIAM WAYNE ETHERTON JR. PT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/03/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1131 W 2ND ST
MOUNT VERNON IN
47620-1773
US

IV. Provider business mailing address

PO BOX 6890
EVANSVILLE IN
47719-0890
US

V. Phone/Fax

Practice location:
  • Phone: 812-838-5406
  • Fax: 812-838-6786
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number05005173A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: