Provider Demographics
NPI:1174143101
Name:DETORE, ASHLEY LYNN (PA)
Entity type:Individual
Prefix:
First Name:ASHLEY
Middle Name:LYNN
Last Name:DETORE
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1350 S ELISEO DR STE 300
Mailing Address - Street 2:
Mailing Address - City:GREENBRAE
Mailing Address - State:CA
Mailing Address - Zip Code:94904-2011
Mailing Address - Country:US
Mailing Address - Phone:415-842-5150
Mailing Address - Fax:
Practice Address - Street 1:1350 S ELISEO DR STE 300
Practice Address - Street 2:
Practice Address - City:GREENBRAE
Practice Address - State:CA
Practice Address - Zip Code:94904-2011
Practice Address - Country:US
Practice Address - Phone:484-332-8149
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-20
Last Update Date:2024-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA61109363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant