MEDICARE: MR. DAVID J ETZEL CNP

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	363L00000X	Nurse Practitioner	12090-NP	OH
2	363LC1500X	Community Health Nurse Practitioner	12090-NP	OH
3	363LF0000X	Family Nurse Practitioner	NP12090	OH

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	12090-NP	OTHER	OH	STATE LICENSE
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1881999555
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. DAVID J ETZEL CNP

Provider Business Mailing Address
First Line	:	600 W. THIRD STREET
Second Line	:
City	:	MANSFIELD
State	:	OH
Zip	:	44906-2633
Country	:	US
Telephone Number	:	419-522-6191
Fax Number	:	419-526-7939

Provider Business Practice Location Address
First Line	:	31 E MAIN ST
Second Line	:
City	:	SHELBY
State	:	OH
Zip	:	44875-1262
Country	:	US
Telephone Number	:	419-525-6795
Fax Number	:	419-525-6723

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

Provider Enumeration Date	:	01/11/2011
Last Update Date	:	05/26/2021

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