Basic Information
| Provider Information | |||||||||
| NPI: | 1134417694 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DEAN | ||||||||
| FirstName: | ASHLEY | ||||||||
| MiddleName: | JAE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | WILSON | ||||||||
| OtherFirstName: | ASHLEY | ||||||||
| OtherMiddleName: | JAE | ||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 300 E MCBEE AVE FL 4 | ||||||||
| Address2: | |||||||||
| City: | GREENVILLE | ||||||||
| State: | SC | ||||||||
| PostalCode: | 296012842 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8645228603 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1316 N LAKE DR | ||||||||
| Address2: | |||||||||
| City: | LEXINGTON | ||||||||
| State: | SC | ||||||||
| PostalCode: | 290727653 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8033581191 | ||||||||
| FaxNumber: | 8033581180 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/19/2011 | ||||||||
| LastUpdateDate: | 02/17/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 02/17/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | LL33685 | SC | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | MD-45827 | IA | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 33685 | SC | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 336853 | 05 | SC | MEDICAID |