Provider Demographics
NPI:1629586946
Name:FERGUSON, ASHLEY (APN)
Entity Type:Individual
Prefix:
First Name:ASHLEY
Middle Name:
Last Name:FERGUSON
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9001 BIRKBECK RD
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:IL
Mailing Address - Zip Code:61727-9166
Mailing Address - Country:US
Mailing Address - Phone:309-846-1073
Mailing Address - Fax:
Practice Address - Street 1:330 N WYCKLES RD
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:IL
Practice Address - Zip Code:62522-1034
Practice Address - Country:US
Practice Address - Phone:217-876-5208
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-22
Last Update Date:2018-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209.016909207QA0505X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL209.016909OtherILLINOIS LICENSE