Provider Demographics
NPI:1588308571
Name:FORT, ETHAN
Entity type:Individual
Prefix:
First Name:ETHAN
Middle Name:
Last Name:FORT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4100 MILLSTONE CIR
Mailing Address - Street 2:
Mailing Address - City:HAYS
Mailing Address - State:KS
Mailing Address - Zip Code:67601-9797
Mailing Address - Country:US
Mailing Address - Phone:785-259-2457
Mailing Address - Fax:
Practice Address - Street 1:2220 CANTERBURY DR
Practice Address - Street 2:
Practice Address - City:HAYS
Practice Address - State:KS
Practice Address - Zip Code:67601-2370
Practice Address - Country:US
Practice Address - Phone:855-429-7633
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-25
Last Update Date:2022-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical