Provider Demographics
NPI:1144652017
Name:STOUT, ETHAN JOHN (PT, DPT)
Entity type:Individual
Prefix:
First Name:ETHAN
Middle Name:JOHN
Last Name:STOUT
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:207 S BURLINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:HASTINGS
Mailing Address - State:NE
Mailing Address - Zip Code:68901-5905
Mailing Address - Country:US
Mailing Address - Phone:402-462-8824
Mailing Address - Fax:
Practice Address - Street 1:207 S BURLINGTON AVE
Practice Address - Street 2:
Practice Address - City:HASTINGS
Practice Address - State:NE
Practice Address - Zip Code:68901-5905
Practice Address - Country:US
Practice Address - Phone:402-462-8824
Practice Address - Fax:402-462-8017
Is Sole Proprietor?:No
Enumeration Date:2013-08-02
Last Update Date:2023-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE3082225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist