Provider Demographics
NPI:1477282515
Name:NELSON, ASHTON IRVIN
Entity Type:Individual
Prefix:
First Name:ASHTON
Middle Name:IRVIN
Last Name:NELSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ASHTON
Other - Middle Name:LYRIC
Other - Last Name:IRVIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1724 FIRST BAXTER XING
Mailing Address - Street 2:
Mailing Address - City:FORT MILL
Mailing Address - State:SC
Mailing Address - Zip Code:29708-8919
Mailing Address - Country:US
Mailing Address - Phone:803-322-7475
Mailing Address - Fax:
Practice Address - Street 1:2848 PLEASANT RD STE 101
Practice Address - Street 2:
Practice Address - City:FORT MILL
Practice Address - State:SC
Practice Address - Zip Code:29708-9494
Practice Address - Country:US
Practice Address - Phone:800-779-4089
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-06
Last Update Date:2023-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP100367E225100000X, 2251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCP100367EMedicaid