Provider Demographics
NPI:1700278835
Name:BULLARD, ASHLEY M (PA-C)
Entity Type:Individual
Prefix:
First Name:ASHLEY
Middle Name:M
Last Name:BULLARD
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 505164
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63150-5164
Mailing Address - Country:US
Mailing Address - Phone:417-829-4620
Mailing Address - Fax:417-829-4316
Practice Address - Street 1:1229 E SEMINOLE ST
Practice Address - Street 2:SUITE 520
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65804-2227
Practice Address - Country:US
Practice Address - Phone:417-820-5750
Practice Address - Fax:417-820-5066
Is Sole Proprietor?:No
Enumeration Date:2015-02-26
Last Update Date:2015-08-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MO2015006219363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOPENDINGMedicaid
MO132300576Medicare PIN
MO132680587Medicare PIN