Provider Demographics
NPI:1144772039
Name:AMBROSE, JENNIFER
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:AMBROSE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 W UTICA ST
Mailing Address - Street 2:
Mailing Address - City:OSWEGO
Mailing Address - State:NY
Mailing Address - Zip Code:13126-3047
Mailing Address - Country:US
Mailing Address - Phone:315-342-2024
Mailing Address - Fax:315-343-5317
Practice Address - Street 1:8393 ELTA DR
Practice Address - Street 2:
Practice Address - City:CICERO
Practice Address - State:NY
Practice Address - Zip Code:13039-8958
Practice Address - Country:US
Practice Address - Phone:315-698-0290
Practice Address - Fax:315-698-0291
Is Sole Proprietor?:No
Enumeration Date:2016-10-26
Last Update Date:2018-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY020229363A00000X
NY020229-1363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1144772039Medicaid