Provider Demographics
NPI:1528618121
Name:GAGER, ETHAN DAVID (NP)
Entity type:Individual
Prefix:
First Name:ETHAN
Middle Name:DAVID
Last Name:GAGER
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1432 CREEK SPRINGS DR
Mailing Address - Street 2:
Mailing Address - City:ALLEN
Mailing Address - State:TX
Mailing Address - Zip Code:75002-0993
Mailing Address - Country:US
Mailing Address - Phone:214-385-5920
Mailing Address - Fax:
Practice Address - Street 1:2700 E ELDORADO PKWY
Practice Address - Street 2:
Practice Address - City:LITTLE ELM
Practice Address - State:TX
Practice Address - Zip Code:75068-5999
Practice Address - Country:US
Practice Address - Phone:972-987-0458
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-16
Last Update Date:2019-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP139837363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX2143855920Medicaid