Healthcare Provider Details

I. General information

NPI: 1801416599
Provider Name (Legal Business Name): ASHLEE DOUGHERTY PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/22/2020
Last Update Date: 10/28/2022
Certification Date: 10/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 MEDICAL PARK DR
MEXICO MO
65265-3724
US

IV. Provider business mailing address

600 MEDICAL PARK DR
MEXICO MO
65265-3724
US

V. Phone/Fax

Practice location:
  • Phone: 573-581-8500
  • Fax: 573-581-5397
Mailing address:
  • Phone: 573-581-8500
  • Fax: 573-581-5397

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number2021011993
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: