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General NPI Number Information
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NPI Number | 1134098833
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Entity Type | Individual
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Provider Name | ETHAN DOE
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Gender | Male
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Dates
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Enumeration Date | 10/31/2025
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Last Update Date | 10/31/2025
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Provider Practice Location Address
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Address Line | 3180 AIRPORT RD
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City | BOULDER
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State | CO
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Zip | 80301-2208
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Country | US
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Telephone | 303-447-1665
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Fax |
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Provider Business Mailing Address
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Address Line | 11823 RIDGE PKWY APT 817
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City | BROOMFIELD
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State | CO
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Zip | 80021-5099
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Country | US
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Telephone | 708-941-7406
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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 | 163WC0400X
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Taxonomy Name | Case Management Registered Nurse
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License Number | RN.1675791
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License Number State | CO
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