Provider Demographics
NPI:1912301540
Name:BOONE, ASHLEY (PA-C)
Entity Type:Individual
Prefix:
First Name:ASHLEY
Middle Name:
Last Name:BOONE
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:PO BOX 776351
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-6351
Mailing Address - Country:US
Mailing Address - Phone:502-588-9490
Mailing Address - Fax:502-272-5116
Practice Address - Street 1:301 GORDON GUTMANN BLVD STE 401
Practice Address - Street 2:
Practice Address - City:JEFFERSONVILLE
Practice Address - State:IN
Practice Address - Zip Code:47130-3768
Practice Address - Country:US
Practice Address - Phone:812-282-0637
Practice Address - Fax:812-283-6330
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-10
Last Update Date:2024-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN10002059A363A00000X
KYTC225363A00000X
OH50.004170363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0112322Medicaid
IN10002059AOtherSTATE LICENSE
OHH410210OtherMEDICARE PTAN
KY7100448950Medicaid
IN300013731Medicaid