Healthcare Provider Details

I. General information

NPI: 1609112978
Provider Name (Legal Business Name): NATHAN ASHBY DPM PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/14/2012
Last Update Date: 12/14/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

124 MARGO LN
FAYETTEVILLE NY
13066-1529
US

IV. Provider business mailing address

124 MARGO LN
FAYETTEVILLE NY
13066-1529
US

V. Phone/Fax

Practice location:
  • Phone: 315-736-2080
  • Fax:
Mailing address:
  • Phone: 315-736-2080
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number005863
License Number StateNY

VIII. Authorized Official

Name: NATHAN ASHBY
Title or Position: OWNER
Credential: DPM
Phone: 315-736-2080