Provider Demographics
NPI:1134521107
Name:MORT, ASHLEY FAYE (PA-C)
Entity type:Individual
Prefix:MRS
First Name:ASHLEY
Middle Name:FAYE
Last Name:MORT
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:ASHLEY
Other - Middle Name:FAYE
Other - Last Name:SENOPOLE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:43151 DALCOMA DR STE 4
Mailing Address - Street 2:
Mailing Address - City:CLINTON TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48038-6306
Mailing Address - Country:US
Mailing Address - Phone:586-286-8720
Mailing Address - Fax:866-790-6803
Practice Address - Street 1:2950 KEEWAHDIN RD
Practice Address - Street 2:
Practice Address - City:FORT GRATIOT
Practice Address - State:MI
Practice Address - Zip Code:48059-3526
Practice Address - Country:US
Practice Address - Phone:810-455-1600
Practice Address - Fax:810-455-1620
Is Sole Proprietor?:No
Enumeration Date:2014-09-22
Last Update Date:2023-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601007084207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology