Provider Demographics
NPI:1518647197
Name:MATA, ASHLEY RENEE (PA)
Entity Type:Individual
Prefix:
First Name:ASHLEY
Middle Name:RENEE
Last Name:MATA
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:ASHLEY
Other - Middle Name:RENEE
Other - Last Name:BROWN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 366
Mailing Address - Street 2:
Mailing Address - City:MC BEE
Mailing Address - State:SC
Mailing Address - Zip Code:29101-0366
Mailing Address - Country:US
Mailing Address - Phone:843-335-8291
Mailing Address - Fax:
Practice Address - Street 1:290 MARKET ST
Practice Address - Street 2:
Practice Address - City:RUBY
Practice Address - State:SC
Practice Address - Zip Code:29741-2900
Practice Address - Country:US
Practice Address - Phone:843-634-6044
Practice Address - Fax:843-634-6600
Is Sole Proprietor?:No
Enumeration Date:2023-07-19
Last Update Date:2023-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC4940363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical