Provider Demographics
NPI:1053566687
Name:MOON, ASHLEY MARIE (PA-C)
Entity type:Individual
Prefix:
First Name:ASHLEY
Middle Name:MARIE
Last Name:MOON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:ASHLEY
Other - Middle Name:MARIE
Other - Last Name:HOLT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:7 DOCK HILL RD
Mailing Address - Street 2:
Mailing Address - City:MIDDLEBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17842-8910
Mailing Address - Country:US
Mailing Address - Phone:570-837-2123
Mailing Address - Fax:570-837-2185
Practice Address - Street 1:1205 RIVER AVE FL 1
Practice Address - Street 2:
Practice Address - City:WILLIAMSPORT
Practice Address - State:PA
Practice Address - Zip Code:17701-3724
Practice Address - Country:US
Practice Address - Phone:570-323-5991
Practice Address - Fax:570-323-6578
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-24
Last Update Date:2022-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA053413363AM0700X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1031581000001Medicaid