Provider Demographics
NPI:1407886286
Name:AMBROSE, DAVID LEWIS SR (AUD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:LEWIS
Last Name:AMBROSE
Suffix:SR
Gender:M
Credentials:AUD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:434 E NORWEGIAN ST
Mailing Address - Street 2:
Mailing Address - City:POTTSVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:17901-3684
Mailing Address - Country:US
Mailing Address - Phone:570-622-1435
Mailing Address - Fax:570-622-7902
Practice Address - Street 1:434 E NORWEGIAN ST
Practice Address - Street 2:
Practice Address - City:POTTSVILLE
Practice Address - State:PA
Practice Address - Zip Code:17901-3684
Practice Address - Country:US
Practice Address - Phone:570-622-1435
Practice Address - Fax:570-622-7902
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-04
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAAT-000023-L237600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid Fitter
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1007588990003Medicaid
PA01742902Medicare UPIN
PA1007588990003Medicaid