Basic Information
| Provider Information | |||||||||
| NPI: | 1194360180 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | EMMONS | ||||||||
| FirstName: | ETHAN | ||||||||
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| Credential: | DPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 907 THOUSAND OAKS DR | ||||||||
| Address2: | |||||||||
| City: | VIRGINIA BEACH | ||||||||
| State: | VA | ||||||||
| PostalCode: | 234543530 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8046272483 | ||||||||
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| Practice Location | |||||||||
| Address1: | 984B LASKIN RD | ||||||||
| Address2: | |||||||||
| City: | VIRGINIA BEACH | ||||||||
| State: | VA | ||||||||
| PostalCode: | 234513905 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7573956900 | ||||||||
| FaxNumber: | 7574257180 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/13/2019 | ||||||||
| LastUpdateDate: | 03/22/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/22/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2251X0800X | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Orthopedic | 225100000X | 2305211904 | VA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.