Provider Demographics
NPI:1366423600
Name:ETHEART, ALBERT A (PA C)
Entity type:Individual
Prefix:MR
First Name:ALBERT
Middle Name:A
Last Name:ETHEART
Suffix:
Gender:M
Credentials:PA C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 30790
Mailing Address - Street 2:MEDINA EMERGENCY ASSOCIATES LTD
Mailing Address - City:MIDDLEBURG HEIGHTS
Mailing Address - State:OH
Mailing Address - Zip Code:44130-0790
Mailing Address - Country:US
Mailing Address - Phone:330-654-1185
Mailing Address - Fax:330-654-9086
Practice Address - Street 1:20300 CHARGRIN BLVD
Practice Address - Street 2:
Practice Address - City:SHAKER HEIGHTS
Practice Address - State:OH
Practice Address - Zip Code:44122-4412
Practice Address - Country:US
Practice Address - Phone:614-505-7633
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-11
Last Update Date:2019-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50001006363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHETPA11669Medicare PIN