Basic Information
| Provider Information | |||||||||
| NPI: | 1356793897 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | NULTON | ||||||||
| FirstName: | ETHAN | ||||||||
| MiddleName: | |||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 565 COAL VALLEY RD | ||||||||
| Address2: | |||||||||
| City: | JEFFERSON HILLS | ||||||||
| State: | PA | ||||||||
| PostalCode: | 150253703 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4122676810 | ||||||||
| FaxNumber: | 4122676817 | ||||||||
| Practice Location | |||||||||
| Address1: | 565 COAL VALLEY RD | ||||||||
| Address2: | |||||||||
| City: | JEFFERSON HILLS | ||||||||
| State: | PA | ||||||||
| PostalCode: | 150253703 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4122676810 | ||||||||
| FaxNumber: | 4122676817 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/08/2016 | ||||||||
| LastUpdateDate: | 10/07/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 10/07/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | OT017160 | PA | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.