Healthcare Provider Details

I. General information

NPI: 1033041207
Provider Name (Legal Business Name): ETHAN CHRISTOPHER WHEELER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/02/2026
Last Update Date: 06/02/2026
Certification Date: 05/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 S LIMESTONE
LEXINGTON KY
40505-3567
US

IV. Provider business mailing address

172 PALISADES PT
LANCASTER KY
40444-8956
US

V. Phone/Fax

Practice location:
  • Phone: 859-323-1100
  • Fax:
Mailing address:
  • Phone: 859-209-1458
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: