Provider Demographics
NPI:1104455989
Name:MULDER, ASHLEY MARIE (MD)
Entity type:Individual
Prefix:
First Name:ASHLEY
Middle Name:MARIE
Last Name:MULDER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:ASHLEY
Other - Middle Name:MARIE
Other - Last Name:DESMARAIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 3539
Mailing Address - Street 2:
Mailing Address - City:LAKE HAVASU CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:86405-3539
Mailing Address - Country:US
Mailing Address - Phone:928-453-2727
Mailing Address - Fax:928-453-2828
Practice Address - Street 1:1987 MCCULLOCH BLVD N STE 101
Practice Address - Street 2:
Practice Address - City:LAKE HAVASU CITY
Practice Address - State:AZ
Practice Address - Zip Code:86403-5770
Practice Address - Country:US
Practice Address - Phone:928-733-6291
Practice Address - Fax:928-733-6294
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-03
Last Update Date:2024-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ69006207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ141544Medicaid