Provider Demographics
NPI:1215473103
Name:REGEN, ETHAN (ATC)
Entity type:Individual
Prefix:MR
First Name:ETHAN
Middle Name:
Last Name:REGEN
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 1:3907 HENRICKS HILL DR
Mailing Address - Street 2:
Mailing Address - City:SMYRNA
Mailing Address - State:TN
Mailing Address - Zip Code:37167-8368
Mailing Address - Country:US
Mailing Address - Phone:615-957-2403
Mailing Address - Fax:
Practice Address - Street 1:2021 CHURCH ST STE 200
Practice Address - Street 2:
Practice Address - City:NASHVILLE
Practice Address - State:TN
Practice Address - Zip Code:37203-2087
Practice Address - Country:US
Practice Address - Phone:615-324-1600
Practice Address - Fax:615-284-2003
Is Sole Proprietor?:No
Enumeration Date:2017-01-16
Last Update Date:2017-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN18732255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer