Provider Demographics
NPI:1366248445
Name:GULLY, ASHTON MARY (PA-C)
Entity type:Individual
Prefix:
First Name:ASHTON
Middle Name:MARY
Last Name:GULLY
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 1:2206 E VILLA MARIA RD
Mailing Address - Street 2:
Mailing Address - City:BRYAN
Mailing Address - State:TX
Mailing Address - Zip Code:77802-2547
Mailing Address - Country:US
Mailing Address - Phone:979-776-4600
Mailing Address - Fax:
Practice Address - Street 1:2206 E VILLA MARIA RD
Practice Address - Street 2:
Practice Address - City:BRYAN
Practice Address - State:TX
Practice Address - Zip Code:77802-2547
Practice Address - Country:US
Practice Address - Phone:979-776-4600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-02-20
Last Update Date:2025-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA18665363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant