Provider Demographics
NPI:1568636306
Name:NORDSTROM, ASHLEY SUZAM (PA-C)
Entity Type:Individual
Prefix:
First Name:ASHLEY
Middle Name:SUZAM
Last Name:NORDSTROM
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:ASHLEY
Other - Middle Name:SUZAM
Other - Last Name:RAVENEL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:898 COLLEGE ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:MONTICELLO
Mailing Address - State:GA
Mailing Address - Zip Code:31064-1258
Mailing Address - Country:US
Mailing Address - Phone:706-468-0988
Mailing Address - Fax:706-468-6631
Practice Address - Street 1:898 COLLEGE ST
Practice Address - Street 2:SUITE A
Practice Address - City:MONTICELLO
Practice Address - State:GA
Practice Address - Zip Code:31064-1258
Practice Address - Country:US
Practice Address - Phone:706-468-0988
Practice Address - Fax:706-468-6631
Is Sole Proprietor?:No
Enumeration Date:2008-04-14
Last Update Date:2014-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA005296363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003141276AMedicaid
GA003141276AMedicaid