Provider Demographics
NPI:1447067681
Name:AJESKA, ETHAN GERALD
Entity type:Individual
Prefix:
First Name:ETHAN
Middle Name:GERALD
Last Name:AJESKA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:65 CIRCLEWOOD
Mailing Address - Street 2:
Mailing Address - City:TUSCALOOSA
Mailing Address - State:AL
Mailing Address - Zip Code:35405-1737
Mailing Address - Country:US
Mailing Address - Phone:831-241-4164
Mailing Address - Fax:
Practice Address - Street 1:65 CIRCLEWOOD
Practice Address - Street 2:
Practice Address - City:TUSCALOOSA
Practice Address - State:AL
Practice Address - Zip Code:35405-1737
Practice Address - Country:US
Practice Address - Phone:831-241-4164
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-12-11
Last Update Date:2024-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer