Provider Demographics
NPI:1043424740
Name:AMBROSE, MARK (PA-C)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:AMBROSE
Suffix:
Gender:M
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 1:16450 104TH AVE
Mailing Address - Street 2:STE 101
Mailing Address - City:ORLAND PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60467-5416
Mailing Address - Country:US
Mailing Address - Phone:708-206-0010
Mailing Address - Fax:708-206-0020
Practice Address - Street 1:3330 W 177TH ST
Practice Address - Street 2:SUITE 3E
Practice Address - City:HAZEL CREST
Practice Address - State:IL
Practice Address - Zip Code:60429-2184
Practice Address - Country:US
Practice Address - Phone:708-206-0010
Practice Address - Fax:708-206-0020
Is Sole Proprietor?:No
Enumeration Date:2007-05-10
Last Update Date:2016-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085000830363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILK18310SCOtherPROVIDER NO.
ILQ46010Medicare UPIN