Provider Demographics
NPI:1871211748
Name:COLE, ETHAN CONALL (IDC)
Entity type:Individual
Prefix:
First Name:ETHAN
Middle Name:CONALL
Last Name:COLE
Suffix:
Gender:M
Credentials:IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:USS FRANK CABLE
Mailing Address - Street 2:UNIT 100105 BOX 216 FPO, AE 96567-0502
Mailing Address - City:AGUANA
Mailing Address - State:GU
Mailing Address - Zip Code:96567
Mailing Address - Country:US
Mailing Address - Phone:717-601-4053
Mailing Address - Fax:
Practice Address - Street 1:USS FRANK CABLE
Practice Address - Street 2:UNIT 100105
Practice Address - City:AGUANA
Practice Address - State:GU
Practice Address - Zip Code:96567
Practice Address - Country:US
Practice Address - Phone:717-601-4053
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-17
Last Update Date:2023-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA390200000X
1710I1002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program