Provider Demographics
NPI:1780086488
Name:THEOBALD, ASHLEY P (PA-C)
Entity type:Individual
Prefix:
First Name:ASHLEY
Middle Name:P
Last Name:THEOBALD
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8 TYLER ST
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29605-2044
Mailing Address - Country:US
Mailing Address - Phone:346-954-9273
Mailing Address - Fax:
Practice Address - Street 1:2 ROPER CORNERS CIR
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29615-4833
Practice Address - Country:US
Practice Address - Phone:864-234-7815
Practice Address - Fax:864-234-7846
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-24
Last Update Date:2022-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN10184225100000X
363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN446631Medicare PIN