Provider Demographics
NPI:1811387806
Name:SPACK, ASHLEE NICOLE (PA-C)
Entity Type:Individual
Prefix:
First Name:ASHLEE
Middle Name:NICOLE
Last Name:SPACK
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:551 W MAHONING ST
Mailing Address - Street 2:
Mailing Address - City:PUNXSUTAWNEY
Mailing Address - State:PA
Mailing Address - Zip Code:15767-1909
Mailing Address - Country:US
Mailing Address - Phone:814-249-7001
Mailing Address - Fax:814-249-7015
Practice Address - Street 1:551 W MAHONING ST
Practice Address - Street 2:
Practice Address - City:PUNXSUTAWNEY
Practice Address - State:PA
Practice Address - Zip Code:15767-1909
Practice Address - Country:US
Practice Address - Phone:814-249-7001
Practice Address - Fax:814-249-7015
Is Sole Proprietor?:No
Enumeration Date:2015-01-28
Last Update Date:2016-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOA003498363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant