Healthcare Provider Details

I. General information

NPI: 1609681972
Provider Name (Legal Business Name): COLTON ASHLEY PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/12/2025
Last Update Date: 07/28/2025
Certification Date: 07/28/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

45 GROOVER LOOP STE 201
ST AUGUSTINE FL
32086-6586
US

IV. Provider business mailing address

6800 SOUTHPOINT PKWY STE 300
JACKSONVILLE FL
32216-8203
US

V. Phone/Fax

Practice location:
  • Phone: 904-634-0640
  • Fax: 904-634-0203
Mailing address:
  • Phone: 904-634-0640
  • Fax: 904-634-0203

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9119954
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: