Provider Demographics
NPI:1295402337
Name:WILSON, ASHTON LEIGH
Entity Type:Individual
Prefix:
First Name:ASHTON
Middle Name:LEIGH
Last Name:WILSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3350 NOYAC RD
Mailing Address - Street 2:
Mailing Address - City:SAG HARBOR
Mailing Address - State:NY
Mailing Address - Zip Code:11963
Mailing Address - Country:US
Mailing Address - Phone:850-814-0262
Mailing Address - Fax:
Practice Address - Street 1:3350 NOYAC RD
Practice Address - Street 2:
Practice Address - City:SAG HARBOR
Practice Address - State:NY
Practice Address - Zip Code:11963
Practice Address - Country:US
Practice Address - Phone:850-814-0262
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-26
Last Update Date:2021-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY027411207N00000X
NY1790070480207N00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program