Healthcare Provider Details

I. General information

NPI: 1982191169
Provider Name (Legal Business Name): ETHAN PRESTON FNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/13/2018
Last Update Date: 03/04/2025
Certification Date: 03/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1502 BLUE RIDGE DR STE 100
GEORGETOWN TX
78626-1002
US

IV. Provider business mailing address

1502 BLUE RIDGE DR STE 100
GEORGETOWN TX
78626-1002
US

V. Phone/Fax

Practice location:
  • Phone: 855-220-9655
  • Fax: 855-220-9655
Mailing address:
  • Phone: 855-220-9655
  • Fax: 855-220-9655

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number4704266333
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number1077676
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: