Provider Demographics
NPI:1528945284
Name:HARGRAVE, ETHAN JAMES
Entity type:Individual
Prefix:
First Name:ETHAN
Middle Name:JAMES
Last Name:HARGRAVE
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 1:45 HOLLISTER ST
Mailing Address - Street 2:
Mailing Address - City:DUNDEE
Mailing Address - State:NY
Mailing Address - Zip Code:14837-1120
Mailing Address - Country:US
Mailing Address - Phone:607-794-7270
Mailing Address - Fax:
Practice Address - Street 1:1793 OUTLET RD
Practice Address - Street 2:
Practice Address - City:PENN YAN
Practice Address - State:NY
Practice Address - Zip Code:14527-8750
Practice Address - Country:US
Practice Address - Phone:302-494-7186
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-08-16
Last Update Date:2025-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY354023164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse