Provider Demographics
NPI:1962790329
Name:KING, ASHLEY RIVARD (PA-C, MPAS)
Entity type:Individual
Prefix:
First Name:ASHLEY
Middle Name:RIVARD
Last Name:KING
Suffix:
Gender:F
Credentials:PA-C, MPAS
Other - Prefix:
Other - First Name:ASHLEY
Other - Middle Name:E
Other - Last Name:RIVARD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:2650 RIDGE AVE
Mailing Address - Street 2:
Mailing Address - City:EVANSTON
Mailing Address - State:IL
Mailing Address - Zip Code:60201-1700
Mailing Address - Country:US
Mailing Address - Phone:773-713-7680
Mailing Address - Fax:
Practice Address - Street 1:836 W WELLINGTON AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60657-5147
Practice Address - Country:US
Practice Address - Phone:773-296-5888
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-07-19
Last Update Date:2024-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085004085363A00000X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant