Healthcare Provider Details

I. General information

NPI: 1063087013
Provider Name (Legal Business Name): ETHAN WILEY BOND ATC, PT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/21/2021
Last Update Date: 08/20/2026
Certification Date: 08/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

105 MEADOW VIEW RD STE 4
BRISTOL TN
37620-1726
US

IV. Provider business mailing address

105 MEADOW VIEW RD STE 4
BRISTOL TN
37620-1726
US

V. Phone/Fax

Practice location:
  • Phone: 423-844-6935
  • Fax:
Mailing address:
  • Phone: 423-844-6935
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number2817
License Number StateTN
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: