Provider Demographics
NPI:1053573212
Name:HEATH, ASHLEY E (PA)
Entity type:Individual
Prefix:
First Name:ASHLEY
Middle Name:E
Last Name:HEATH
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 945934
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30394-5934
Mailing Address - Country:US
Mailing Address - Phone:770-788-0620
Mailing Address - Fax:678-342-3327
Practice Address - Street 1:4155 BAKER STREET NE
Practice Address - Street 2:SUITE 100
Practice Address - City:COVINGTON
Practice Address - State:GA
Practice Address - Zip Code:30014-1405
Practice Address - Country:US
Practice Address - Phone:770-788-0620
Practice Address - Fax:678-342-3327
Is Sole Proprietor?:No
Enumeration Date:2008-06-30
Last Update Date:2009-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA004829363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA395905293AMedicaid
GA9894144OtherAETNA
GAP00658359OtherMEDICARE - RAILROAD
GA31748348OtherNPPN
GAP00658359OtherMEDICARE - RAILROAD