Basic Information
| Provider Information | |||||||||
| NPI: | 1558654806 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MATNEY | ||||||||
| FirstName: | ASHLEY | ||||||||
| MiddleName: | ROE JESSIE | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1704 W STOCKTON ST | ||||||||
| Address2: | |||||||||
| City: | EDMONTON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 421298137 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2704324800 | ||||||||
| FaxNumber: | 2704324804 | ||||||||
| Practice Location | |||||||||
| Address1: | 1704 W STOCKTON ST | ||||||||
| Address2: | |||||||||
| City: | EDMONTON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 421298137 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2704324800 | ||||||||
| FaxNumber: | 2704324804 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/19/2011 | ||||||||
| LastUpdateDate: | 06/14/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/14/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 48197 | KY | N | Allopathic & Osteopathic Physicians | Pediatrics | 207R00000X | 48197 | KY | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 7100358370 | 05 | KY | MEDICAID |