Provider Demographics
NPI:1487655106
Name:WILSON, ASHLEY SMITH (PA)
Entity type:Individual
Prefix:MRS
First Name:ASHLEY
Middle Name:SMITH
Last Name:WILSON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:ASHLEY
Other - Middle Name:L
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:PO BOX 3439
Mailing Address - Street 2:
Mailing Address - City:NORTH MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29582-0439
Mailing Address - Country:US
Mailing Address - Phone:843-839-4447
Mailing Address - Fax:843-399-0123
Practice Address - Street 1:945 82ND PARKWAY
Practice Address - Street 2:
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29572
Practice Address - Country:US
Practice Address - Phone:843-497-5929
Practice Address - Fax:866-778-9608
Is Sole Proprietor?:No
Enumeration Date:2005-08-03
Last Update Date:2023-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCA525363AM0700X
SC525363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCS795047095Medicare PIN
SCS79504Medicare UPIN