Healthcare Provider Details

I. General information

NPI: 1164663589
Provider Name (Legal Business Name): ETHAN ANDREW NAYBACK AT-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/14/2009
Last Update Date: 06/23/2022
Certification Date: 06/23/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3905 LEONARD ST
MARNE MI
49435-9721
US

IV. Provider business mailing address

3905 LEONARD ST
MARNE MI
49435-9721
US

V. Phone/Fax

Practice location:
  • Phone: 616-558-2715
  • Fax:
Mailing address:
  • Phone: 616-558-2715
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: