Provider Demographics
NPI:1447666037
Name:ROBERTS, ETHAN (ATC)
Entity type:Individual
Prefix:MR
First Name:ETHAN
Middle Name:
Last Name:ROBERTS
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1916 HAUGHTON AVE APT 1
Mailing Address - Street 2:
Mailing Address - City:NORTH MANKATO
Mailing Address - State:MN
Mailing Address - Zip Code:56003-1440
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1916 HAUGHTON AVE APT 1
Practice Address - Street 2:
Practice Address - City:NORTH MANKATO
Practice Address - State:MN
Practice Address - Zip Code:56003-1440
Practice Address - Country:US
Practice Address - Phone:507-995-7937
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-03
Last Update Date:2014-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND8340448516152255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer