Provider Demographics
NPI:1962752279
Name:REID, ASHLEY NICHOLE (PA)
Entity type:Individual
Prefix:
First Name:ASHLEY
Middle Name:NICHOLE
Last Name:REID
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 1:2040 TAMIAMI TRL
Mailing Address - Street 2:SUITE C
Mailing Address - City:PORT CHARLOTTE
Mailing Address - State:FL
Mailing Address - Zip Code:33948-2178
Mailing Address - Country:US
Mailing Address - Phone:941-629-4464
Mailing Address - Fax:941-629-4701
Practice Address - Street 1:2040 TAMIAMI TRL
Practice Address - Street 2:SUITE C
Practice Address - City:PORT CHARLOTTE
Practice Address - State:FL
Practice Address - Zip Code:33948-2178
Practice Address - Country:US
Practice Address - Phone:941-629-4464
Practice Address - Fax:941-629-4701
Is Sole Proprietor?:No
Enumeration Date:2012-09-13
Last Update Date:2014-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPAT9106772363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL007956400Medicaid