Provider Demographics
NPI:1104271949
Name:SKINNER, ETHAN (ATC)
Entity type:Individual
Prefix:
First Name:ETHAN
Middle Name:
Last Name:SKINNER
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:779 W SPROUL RD
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:PA
Mailing Address - Zip Code:19064-1215
Mailing Address - Country:US
Mailing Address - Phone:703-798-5687
Mailing Address - Fax:
Practice Address - Street 1:4110 SPRUCE ST
Practice Address - Street 2:APT. 2
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19104-4077
Practice Address - Country:US
Practice Address - Phone:703-798-5687
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-04-29
Last Update Date:2018-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer