Provider Demographics
NPI:1750734661
Name:MELLERT, ASHLEY EBERSOLE (PA-C)
Entity type:Individual
Prefix:MRS
First Name:ASHLEY
Middle Name:EBERSOLE
Last Name:MELLERT
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MISS
Other - First Name:ASHLEY
Other - Middle Name:NICOLE
Other - Last Name:EBERSOLE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:4605 MACCORKLE AVE SW
Mailing Address - Street 2:THS PHYSICIAN PARTNERS, INC. ADMINISTRATIVE OFC.
Mailing Address - City:SOUTH CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25309-1311
Mailing Address - Country:US
Mailing Address - Phone:304-414-4800
Mailing Address - Fax:304-414-4801
Practice Address - Street 1:500 POPLAR ST STE 204
Practice Address - Street 2:
Practice Address - City:SOUTH CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25309-1472
Practice Address - Country:US
Practice Address - Phone:304-414-2895
Practice Address - Fax:304-414-2898
Is Sole Proprietor?:No
Enumeration Date:2016-07-14
Last Update Date:2021-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV1994363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810024049OtherGROUP MEDICAID
WVB441OtherMEDICARE-GROUP
WV3810024049OtherGROUP MEDICAID