Provider Demographics
NPI:1093226557
Name:DOMZALSKI, ASHLEY (MSPAS)
Entity type:Individual
Prefix:
First Name:ASHLEY
Middle Name:
Last Name:DOMZALSKI
Suffix:
Gender:F
Credentials:MSPAS
Other - Prefix:
Other - First Name:ASHLEY
Other - Middle Name:
Other - Last Name:GOMOLA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:72 HEMLOCK DR
Mailing Address - Street 2:
Mailing Address - City:GLEN MILLS
Mailing Address - State:PA
Mailing Address - Zip Code:19342-1125
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:100 E LANCASTER AVE
Practice Address - Street 2:SUITE 256 MOB EAST
Practice Address - City:WYNNEWOOD
Practice Address - State:PA
Practice Address - Zip Code:19096-3432
Practice Address - Country:US
Practice Address - Phone:610-642-6437
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-23
Last Update Date:2024-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ363A00000X
PAMA060142363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant