Provider Demographics
NPI:1437675097
Name:AMBIO, GRACE (PA-C)
Entity Type:Individual
Prefix:
First Name:GRACE
Middle Name:
Last Name:AMBIO
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 1:170 LYNDALE AVE
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10312-5540
Mailing Address - Country:US
Mailing Address - Phone:718-510-3284
Mailing Address - Fax:
Practice Address - Street 1:355 BARD AVE
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10310-1664
Practice Address - Country:US
Practice Address - Phone:718-818-1234
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-16
Last Update Date:2017-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant