Healthcare Provider Details

I. General information

NPI: 1710277769
Provider Name (Legal Business Name): ETHAN CHRISTOPHER BASSETT M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/12/2011
Last Update Date: 08/11/2026
Certification Date: 08/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9200 W WISCONSIN AVE
MILWAUKEE WI
53226-3522
US

IV. Provider business mailing address

9200 W WISCONSIN AVE
MILWAUKEE WI
53226-3522
US

V. Phone/Fax

Practice location:
  • Phone: 414-805-5580
  • Fax: 414-476-4701
Mailing address:
  • Phone: 414-805-5580
  • Fax: 414-476-4701

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207YP0228X
TaxonomyPediatric Otolaryngology Physician
License Number87457-20
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: