Provider Demographics
NPI:1265118350
Name:BURNETT, ASHLEY NICOLE (PA-C)
Entity type:Individual
Prefix:
First Name:ASHLEY
Middle Name:NICOLE
Last Name:BURNETT
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4029 DEAN MARTIN DR
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89103-4138
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:655 REDWOOD HWY
Practice Address - Street 2:STE 246
Practice Address - City:MILL VALLEY
Practice Address - State:CA
Practice Address - Zip Code:94941-3055
Practice Address - Country:US
Practice Address - Phone:805-590-8099
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-23
Last Update Date:2025-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA65576363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical