Provider Demographics
NPI:1902645666
Name:WHELAN, ETHAN MACCOY
Entity type:Individual
Prefix:
First Name:ETHAN
Middle Name:MACCOY
Last Name:WHELAN
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 1:8120 SW 52ND LN
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32608-7435
Mailing Address - Country:US
Mailing Address - Phone:862-244-7210
Mailing Address - Fax:
Practice Address - Street 1:8120 SW 52ND LN
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32608-7435
Practice Address - Country:US
Practice Address - Phone:862-244-7210
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-22
Last Update Date:2024-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer