Provider Demographics
NPI:1700678778
Name:AUSTELL, ETHAN TANNER
Entity type:Individual
Prefix:
First Name:ETHAN
Middle Name:TANNER
Last Name:AUSTELL
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 1:2734 FORT AVE APT 218
Mailing Address - Street 2:
Mailing Address - City:LYNCHBURG
Mailing Address - State:VA
Mailing Address - Zip Code:24501-3368
Mailing Address - Country:US
Mailing Address - Phone:904-607-1418
Mailing Address - Fax:
Practice Address - Street 1:2734 FORT AVE APT 218
Practice Address - Street 2:
Practice Address - City:LYNCHBURG
Practice Address - State:VA
Practice Address - Zip Code:24501-3368
Practice Address - Country:US
Practice Address - Phone:904-607-1418
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-05-19
Last Update Date:2025-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer