Healthcare Provider Details

I. General information

NPI: 1457580193
Provider Name (Legal Business Name): ASHLEY M KENTOSKI PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/02/2009
Last Update Date: 03/22/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

90 BEAVER DR STE 215D
DU BOIS PA
15801-2442
US

IV. Provider business mailing address

90 BEAVER DR STE 215D
DU BOIS PA
15801-2442
US

V. Phone/Fax

Practice location:
  • Phone: 814-503-8368
  • Fax: 814-503-8562
Mailing address:
  • Phone: 814-503-8368
  • Fax: 814-503-8562

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberMA053865
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: