Provider Demographics
NPI:1053728477
Name:ALDERMAN, ETHAN (MS ATC)
Entity type:Individual
Prefix:
First Name:ETHAN
Middle Name:
Last Name:ALDERMAN
Suffix:
Gender:M
Credentials:MS ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 VERMILLION ST
Mailing Address - Street 2:
Mailing Address - City:ATHENS
Mailing Address - State:WV
Mailing Address - Zip Code:24712-9027
Mailing Address - Country:US
Mailing Address - Phone:304-384-5954
Mailing Address - Fax:
Practice Address - Street 1:2105 MORGAN WOODWARD WAY
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:TX
Practice Address - Zip Code:76006-2671
Practice Address - Country:US
Practice Address - Phone:607-342-8826
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-17
Last Update Date:2018-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
2255A2300X
TXAT58062255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer