Provider Demographics
NPI:1942734538
Name:TAM, ASHLIE (DO)
Entity Type:Individual
Prefix:
First Name:ASHLIE
Middle Name:
Last Name:TAM
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:ASHLIE
Other - Middle Name:CONWAY
Other - Last Name:TAM
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DO
Mailing Address - Street 1:2 JAMES WAY STE 209
Mailing Address - Street 2:
Mailing Address - City:PISMO BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:93449-4976
Mailing Address - Country:US
Mailing Address - Phone:805-549-6915
Mailing Address - Fax:805-549-6916
Practice Address - Street 1:2 JAMES WAY STE 209
Practice Address - Street 2:
Practice Address - City:PISMO BEACH
Practice Address - State:CA
Practice Address - Zip Code:93449-4976
Practice Address - Country:US
Practice Address - Phone:805-739-3474
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-20
Last Update Date:2023-11-08
Deactivation Date:2021-09-14
Deactivation Code:
Reactivation Date:2021-10-18
Provider Licenses
StateLicense IDTaxonomies
MDH89551208000000X
CA20A18370208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics