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General NPI Number Information
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NPI Number | 1093614554
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Entity Type | Individual
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Provider Name | ETHAN GERARD ETTEL ATC, LAT
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Gender | Male
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Dates
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Enumeration Date | 11/02/2026
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Last Update Date | 11/02/2026
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Provider Practice Location Address
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Address Line | 4440 S WASHINGTON ST
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City | GRAND FORKS
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State | ND
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Zip | 58201-7245
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Country | US
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Telephone | 701-732-7700
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Fax |
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Provider Business Mailing Address
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Address Line | 1919 UNIVERSITY DR N APT 225
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City | FARGO
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State | ND
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Zip | 58102-1843
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Country | US
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Telephone | 320-429-1321
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2255A2300X
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Taxonomy Name | Athletic Trainer
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License Number | 1251-26
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License Number State | ND
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