Provider Demographics
NPI:1730448366
Name:ANDERSON, ASHLEY HARTT (DO)
Entity type:Individual
Prefix:
First Name:ASHLEY
Middle Name:HARTT
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:ASHLEY
Other - Middle Name:ERIN
Other - Last Name:HARTT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:3400 DATA DR
Mailing Address - Street 2:ATTN: CREDENTIALING/PAYER ENROLLMENT
Mailing Address - City:RANCHO CORDOVA
Mailing Address - State:CA
Mailing Address - Zip Code:95670-7956
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2330 W COVELL BLVD
Practice Address - Street 2:
Practice Address - City:DAVIS
Practice Address - State:CA
Practice Address - Zip Code:95616-5658
Practice Address - Country:US
Practice Address - Phone:530-668-2600
Practice Address - Fax:530-756-5917
Is Sole Proprietor?:No
Enumeration Date:2012-05-16
Last Update Date:2024-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A16535207Q00000X
TXBP10044788390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX343787YMJUMedicare UPIN