Healthcare Provider Details

I. General information

NPI: 1174404214
Provider Name (Legal Business Name): ETHAN WILSON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/08/2025
Last Update Date: 09/08/2025
Certification Date: 09/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

901 S 4TH ST
LOUISVILLE KY
40203-2188
US

IV. Provider business mailing address

11306 COTTAGE VIEW CT
LOUISVILLE KY
40299-4393
US

V. Phone/Fax

Practice location:
  • Phone: 502-585-9911
  • Fax:
Mailing address:
  • Phone:
  • 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: