Provider Demographics
NPI:1235945940
Name:WILSON, ETHAN (LMP)
Entity type:Individual
Prefix:
First Name:ETHAN
Middle Name:
Last Name:WILSON
Suffix:
Gender:M
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26832 MAPLE VALLEY BLACK DIAMOND RD SE
Mailing Address - Street 2:
Mailing Address - City:MAPLE VALLEY
Mailing Address - State:WA
Mailing Address - Zip Code:98038-8309
Mailing Address - Country:US
Mailing Address - Phone:425-433-6583
Mailing Address - Fax:
Practice Address - Street 1:26832 MAPLE VALLEY BLACK DIAMOND RD SE
Practice Address - Street 2:
Practice Address - City:MAPLE VALLEY
Practice Address - State:WA
Practice Address - Zip Code:98038-8309
Practice Address - Country:US
Practice Address - Phone:425-433-6583
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-12-06
Last Update Date:2024-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist