1932753100 NPI number — ETHAN JOHN MYTINGER

Table of content: ETHAN JOHN MYTINGER (NPI 1932753100)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1932753100 NPI number — ETHAN JOHN MYTINGER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MYTINGER
Provider First Name:
ETHAN
Provider Middle Name:
JOHN
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:
1932753100
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/01/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3333 S BANNOCK ST STE 350
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ENGLEWOOD
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
80110-2426
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
303-957-1310
Provider Business Mailing Address Fax Number:
303-761-4252

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1601 E 19TH AVE STE 5500
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DENVER
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
80218-1291
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
303-777-7112
Provider Business Practice Location Address Fax Number:
303-722-7010
Provider Enumeration Date:
07/26/2019

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: 363A00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 6000000003748572 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 9000181996 , issued by the state of ( CO ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com