MEDICARE: DANA ETHEREDGE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225200000X	Physical Therapy Assistant	2106556	TX

General Provider Information

NPI Number	:	1851799605
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DANA ETHEREDGE

Provider Business Mailing Address
First Line	:	1913 PAYNE AVE
Second Line	:
City	:	AUSTIN
State	:	TX
Zip	:	78757-3203
Country	:	US
Telephone Number	:	512-785-5742
Fax Number	:

Provider Business Practice Location Address
First Line	:	4681 COLLEGE PARK
Second Line	:
City	:	ROUND ROCK
State	:	TX
Zip	:	78665-1526
Country	:	US
Telephone Number	:	512-663-0718
Fax Number	:	512-706-1956

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/10/2014
Last Update Date	:	12/10/2014

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Directions to “ DANA ETHEREDGE ” Practice Location

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