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General NPI Number Information
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NPI Number | 1407370646
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Entity Type | Individual
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Provider Name | ETHAN WILLEY ATC
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Gender | Male
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Dates
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Enumeration Date | 07/31/2017
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Last Update Date | 07/31/2017
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Provider Practice Location Address
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Address Line | 5103 STATION RD
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City | ERIE
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State | PA
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Zip | 16563-4304
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Country | US
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Telephone | 814-898-6017
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Fax |
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Provider Business Mailing Address
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Address Line | 6592 BUFFALO RD APT 2
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City | HARBORCREEK
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State | PA
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Zip | 16421-1160
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Country | US
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Telephone | 13025316262
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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 | RT006072
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License Number State | PA
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