Basic Information
| Provider Information | |||||||||
| NPI: | 1982191169 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PRESTON | ||||||||
| FirstName: | ETHAN | ||||||||
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| Credential: | FNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1279 HARPST ST | ||||||||
| Address2: | |||||||||
| City: | ANN ARBOR | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481046131 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3136836981 | ||||||||
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| Practice Location | |||||||||
| Address1: | 25990 CROCKER BLVD | ||||||||
| Address2: | |||||||||
| City: | HARRISON TOWNSHIP | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480453450 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5864655501 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/13/2018 | ||||||||
| LastUpdateDate: | 04/13/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 4704266333 | MI | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.