Basic Information
| Provider Information | |||||||||
| NPI: | 1881999555 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ETZEL | ||||||||
| FirstName: | DAVID | ||||||||
| MiddleName: | J | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | CNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 600 W. THIRD STREET | ||||||||
| Address2: | |||||||||
| City: | MANSFIELD | ||||||||
| State: | OH | ||||||||
| PostalCode: | 449062633 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4195226191 | ||||||||
| FaxNumber: | 4195267939 | ||||||||
| Practice Location | |||||||||
| Address1: | 31 E MAIN ST | ||||||||
| Address2: | |||||||||
| City: | SHELBY | ||||||||
| State: | OH | ||||||||
| PostalCode: | 448751262 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4195256795 | ||||||||
| FaxNumber: | 4195256723 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/11/2011 | ||||||||
| LastUpdateDate: | 05/26/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/26/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 12090-NP | OH | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363LC1500X | 12090-NP | OH | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Community Health | 363LF0000X | NP12090 | OH | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 12090-NP | 01 | OH | STATE LICENSE | OTHER | 3110449 | 05 | OH | MEDICAID |