=====================================================
General NPI Number Information
=====================================================
NPI Number | 1376413450
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ETHAN JACOB HOLLIS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/05/2025
-----------------------------------------------------
Last Update Date | 11/05/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 420 E UNIVERSITY DR
-----------------------------------------------------
City | DENTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76209-2095
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 580-630-5806
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3789 OLD HIGHWAY 70
-----------------------------------------------------
City | ARDMORE
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73401-0577
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 940-297-6500
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 376K00000X
-----------------------------------------------------
Taxonomy Name | Nurse's Aide
-----------------------------------------------------
License Number | P9L2R2C7
-----------------------------------------------------
License Number State | OK
-----------------------------------------------------