1093263576 NPI number — ETHAN DINAN

Table of content: ETHAN DINAN (NPI 1093263576)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093263576 NPI number — ETHAN DINAN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DINAN
Provider First Name:
ETHAN
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1093263576
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/14/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
655 NORTHERN BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SOUTH ABINGTON TOWNSHIP
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
18411-8740
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
570-842-9323
Provider Business Mailing Address Fax Number:
570-842-9362

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
417 GROW AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MONTROSE
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
18801-1105
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
570-278-1101
Provider Business Practice Location Address Fax Number:
570-278-1102
Provider Enumeration Date:
09/14/2016

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  PT025568 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)