Healthcare Provider Details

I. General information

NPI: 1154267235
Provider Name (Legal Business Name): ETHAN TARVER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/28/2026
Last Update Date: 04/28/2026
Certification Date: 04/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1146 ALMON CIR
GILLETTE WY
82718-6265
US

IV. Provider business mailing address

1146 ALMON CIR
GILLETTE WY
82718-6265
US

V. Phone/Fax

Practice location:
  • Phone: 307-689-4342
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: