Provider Demographics
NPI:1114083680
Name:MOODY, ASHLEY TUMLIN (PA-C)
Entity Type:Individual
Prefix:
First Name:ASHLEY
Middle Name:TUMLIN
Last Name:MOODY
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:PO BOX 3239
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:SC
Mailing Address - Zip Code:29502-3239
Mailing Address - Country:US
Mailing Address - Phone:843-777-7120
Mailing Address - Fax:843-777-7102
Practice Address - Street 1:101 S RAVENEL ST
Practice Address - Street 2:SUITE 230
Practice Address - City:FLORENCE
Practice Address - State:SC
Practice Address - Zip Code:29506-2618
Practice Address - Country:US
Practice Address - Phone:843-777-7043
Practice Address - Fax:843-777-7041
Is Sole Proprietor?:No
Enumeration Date:2006-12-29
Last Update Date:2021-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC730363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC0503PAMedicaid
SCP52971Medicare UPIN