Healthcare Provider Details

I. General information

NPI: 1669287074
Provider Name (Legal Business Name): ASHTON JACOB PEASLEY EMT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/12/2025
Last Update Date: 02/12/2025
Certification Date: 02/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

613 GAYLEY AVE
LOS ANGELES CA
90024-2409
US

IV. Provider business mailing address

613 GAYLEY AVE
LOS ANGELES CA
90024-2409
US

V. Phone/Fax

Practice location:
  • Phone: 949-304-4774
  • Fax:
Mailing address:
  • Phone: 949-304-4774
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code146N00000X
TaxonomyBasic Emergency Medical Technician
License NumberE195286
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: