MEDICARE: ASHLEY PARK PA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant

General Provider Information

NPI Number	:	1730926155
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ASHLEY PARK PA-C

Provider Business Mailing Address
First Line	:	2502 SKYLAND DR NE
Second Line	:
City	:	BROOKHAVEN
State	:	GA
Zip	:	30319-3723
Country	:	US
Telephone Number	:	770-633-5269
Fax Number	:

Provider Business Practice Location Address
First Line	:	2716 PIEDMONT RD NE
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30305-2766
Country	:	US
Telephone Number	:	770-464-6000
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/12/2024
Last Update Date	:	07/12/2024

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Directions to “ ASHLEY PARK PA-C” Practice Location

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