Basic Information
| Provider Information | |||||||||
| NPI: | 1346700796 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PETERSON | ||||||||
| FirstName: | ASHLEY | ||||||||
| MiddleName: | ROXANNE | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 480 MIDDLE ST | ||||||||
| Address2: | |||||||||
| City: | PORTSMOUTH | ||||||||
| State: | VA | ||||||||
| PostalCode: | 237042804 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6783145861 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1022 CALHOUN ST # 201 | ||||||||
| Address2: | |||||||||
| City: | COLUMBIA | ||||||||
| State: | SC | ||||||||
| PostalCode: | 292012406 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8036104199 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/21/2019 | ||||||||
| LastUpdateDate: | 09/23/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/23/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 87776 | SC | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.