Basic Information
| Provider Information | |||||||||
| NPI: | 1477540169 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PARK | ||||||||
| FirstName: | ASHLEY | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1400 S GERMANTOWN RD | ||||||||
| Address2: | |||||||||
| City: | GERMANTOWN | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381382205 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9017593100 | ||||||||
| FaxNumber: | 9017593196 | ||||||||
| Practice Location | |||||||||
| Address1: | 1400 S GERMANTOWN RD | ||||||||
| Address2: | |||||||||
| City: | GERMANTOWN | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381382205 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9017593100 | ||||||||
| FaxNumber: | 9017593196 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/29/2005 | ||||||||
| LastUpdateDate: | 10/06/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/06/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2081P2900X | 26245 | TN | N | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | Pain Medicine | 208100000X | 26245 | TN | Y | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation |
ID Information
| ID | Type | State | Issuer | Description | 06629278 | 05 | MS | MEDICAID | 100156885 | 05 | MS | MEDICAID | 100156886 | 05 | MS | MEDICAID | Q016952 | 05 | TN | MEDICAID | 145915001 | 05 | AR | MEDICAID | 100156887 | 05 | MS | MEDICAID |