Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 225100000X | Physical Therapist | 008448 | KY |
Y | 2251X0800X | Physical Therapist - Orthopedic |
NPI | 1063185551 |
---|---|
Provider Name | Dr. Michael Bryan Ethington |
First Address | Louisville, KY 40291-4522 |
Second Address | Louisville, KY 40291-4522 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 29/07/2021 |
Last Update Date | 03/12/2021 |