Healthcare Provider Details

I. General information

NPI: 1104139153
Provider Name (Legal Business Name): ASHLEY LYNN MATLACK PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/20/2010
Last Update Date: 08/16/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2104 HARRISBURG PIKE STE 200
LANCASTER PA
17601-2644
US

IV. Provider business mailing address

2104 HARRISBURG PIKE STE 200
LANCASTER PA
17601-2644
US

V. Phone/Fax

Practice location:
  • Phone: 717-544-3626
  • Fax: 717-544-3628
Mailing address:
  • Phone: 717-544-3626
  • Fax: 717-544-3628

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberMA054370
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberMA054370
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: