Provider Demographics
NPI:1861121089
Name:VETTLESON, ASHLEY NICOLE (PA-C)
Entity type:Individual
Prefix:
First Name:ASHLEY
Middle Name:NICOLE
Last Name:VETTLESON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:ASHLEY
Other - Middle Name:NICOLE
Other - Last Name:LONGTIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3065 DEMERS AVE
Mailing Address - Street 2:
Mailing Address - City:GRAND FORKS
Mailing Address - State:ND
Mailing Address - Zip Code:58201
Mailing Address - Country:US
Mailing Address - Phone:701-780-1891
Mailing Address - Fax:
Practice Address - Street 1:1845 HWY 59 S
Practice Address - Street 2:SUITE 800
Practice Address - City:THIEF RIVER FALLS
Practice Address - State:MN
Practice Address - Zip Code:56701-4336
Practice Address - Country:US
Practice Address - Phone:218-681-7280
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-06
Last Update Date:2024-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363AM0700X
MN14720363A00000X
NDPAC1043363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical