Individual
ETHAN WADE TAYLOR
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Contact information
Practice address
1350 S MULDROW ST, TISHOMINGO, OK 73460-3278
(830) 928-6990
Mailing address
1350 S MULDROW ST, TISHOMINGO, OK 73460-3278
(830) 928-6990
Taxonomy
Speciality
Code
Description
License number
State
171M00000X
Case Manager/Care Coordinator
Primary
—
—
Other
Enumeration date
05/14/2013
Last updated
05/14/2013
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