Healthcare Provider Details

I. General information

NPI: 1407370646
Provider Name (Legal Business Name): ETHAN WILLEY ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/31/2017
Last Update Date: 05/02/2026
Certification Date: 05/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

59 S BROWN ST
RHINELANDER WI
54501-3450
US

IV. Provider business mailing address

59 S BROWN ST
RHINELANDER WI
54501-3450
US

V. Phone/Fax

Practice location:
  • Phone: 715-513-6121
  • Fax:
Mailing address:
  • Phone: 715-513-6121
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number2402-39
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: