Healthcare Provider Details

I. General information

NPI: 1730723578
Provider Name (Legal Business Name): ASHLEY MATTERN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/05/2019
Last Update Date: 12/21/2023
Certification Date: 12/21/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3605 ACADEMY ST
DEARBORN MI
48124-3382
US

IV. Provider business mailing address

5301 MCAULEY DR
YPSILANTI MI
48197-1051
US

V. Phone/Fax

Practice location:
  • Phone: 313-819-0941
  • Fax:
Mailing address:
  • Phone: 734-712-3456
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number2601001677
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5601011831
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: