Basic Information
| Provider Information | |||||||||
| NPI: | 1417438714 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MASTERSON | ||||||||
| FirstName: | ASHLEY | ||||||||
| MiddleName: | BROADWAY | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | DO | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 1523 HAMNER HOLLOW RD | ||||||||
| Address2: | |||||||||
| City: | BIG STONE GAP | ||||||||
| State: | VA | ||||||||
| PostalCode: | 242194433 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4238275379 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1990 HOLTON AVE E | ||||||||
| Address2: | |||||||||
| City: | BIG STONE GAP | ||||||||
| State: | VA | ||||||||
| PostalCode: | 242193350 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2765233111 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/24/2018 | ||||||||
| LastUpdateDate: | 02/11/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 02/11/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 0116032308 | VA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.