Provider Demographics
NPI:1326694076
Name:AMBROSE, NATHAN J (PA)
Entity Type:Individual
Prefix:
First Name:NATHAN
Middle Name:J
Last Name:AMBROSE
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:1132 GATHER DR
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30043-7549
Mailing Address - Country:US
Mailing Address - Phone:810-625-4218
Mailing Address - Fax:
Practice Address - Street 1:5000 AMBASSADOR CAFFERY PKWY STE A
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70508-6984
Practice Address - Country:US
Practice Address - Phone:337-470-3580
Practice Address - Fax:337-470-3586
Is Sole Proprietor?:No
Enumeration Date:2019-08-16
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
390200000X
LA324792363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA058924-PAOtherCDS
LA324792OtherSTATE LICENSE
LA324792OtherSTATE LICENSE