Provider Demographics
NPI:1104139153
Name:MATLACK, ASHLEY LYNN (PA-C)
Entity type:Individual
Prefix:
First Name:ASHLEY
Middle Name:LYNN
Last Name:MATLACK
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2104 HARRISBURG PIKE STE 200
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:PA
Mailing Address - Zip Code:17601-2644
Mailing Address - Country:US
Mailing Address - Phone:717-544-3626
Mailing Address - Fax:717-544-3628
Practice Address - Street 1:2104 HARRISBURG PIKE STE 200
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:PA
Practice Address - Zip Code:17601-2644
Practice Address - Country:US
Practice Address - Phone:717-544-3626
Practice Address - Fax:717-544-3628
Is Sole Proprietor?:No
Enumeration Date:2010-07-20
Last Update Date:2013-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA054370363AS0400X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical