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General NPI Number Information
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NPI Number | 1134089949
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Entity Type | Individual
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Provider Name | ETHAN A SANDERS APRN
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Gender | Male
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Dates
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Enumeration Date | 11/13/2025
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Last Update Date | 12/01/2025
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Provider Practice Location Address
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Address Line | 2300 N EDWARD ST
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City | DECATUR
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State | IL
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Zip | 62526-4192
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Country | US
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Telephone | 217-876-8121
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Fax |
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Provider Business Mailing Address
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Address Line | 2300 N EDWARD ST STE 2400
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City | DECATUR
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State | IL
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Zip | 62526-4192
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Country | US
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Telephone | 217-876-2400
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Fax | 217-876-2405
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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 | 363LG0600X
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Taxonomy Name | Gerontology Nurse Practitioner
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License Number | 209.033959
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License Number State | IL
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Taxonomy #2
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Taxonomy Code | 363LA2100X
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Taxonomy Name | Acute Care Nurse Practitioner
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License Number | 209.033959
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License Number State | IL
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