Provider Demographics
NPI:1407662257
Name:DELEKTA, ETHAN M (PA-C)
Entity type:Individual
Prefix:MR
First Name:ETHAN
Middle Name:M
Last Name:DELEKTA
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 814
Mailing Address - Street 2:
Mailing Address - City:NEW CUMBERLAND
Mailing Address - State:WV
Mailing Address - Zip Code:26047-0814
Mailing Address - Country:US
Mailing Address - Phone:304-374-5039
Mailing Address - Fax:
Practice Address - Street 1:333 N COMMERCIAL ST STE 100
Practice Address - Street 2:
Practice Address - City:NEENAH
Practice Address - State:WI
Practice Address - Zip Code:54956-2675
Practice Address - Country:US
Practice Address - Phone:920-722-1750
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-12-06
Last Update Date:2025-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI8509-23363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant