Provider Demographics
NPI:1487676862
Name:AMBROSE, JOHN W (CRNA)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:W
Last Name:AMBROSE
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:LAHEY HOSPITAL AND MEDICAL CENTER
Mailing Address - Street 2:41 MALL ROAD
Mailing Address - City:BURLINGTON
Mailing Address - State:MA
Mailing Address - Zip Code:01805
Mailing Address - Country:US
Mailing Address - Phone:817-744-8085
Mailing Address - Fax:
Practice Address - Street 1:LAHEY CLINIC INC
Practice Address - Street 2:41 MALL ROAD
Practice Address - City:BURLINGTON
Practice Address - State:MA
Practice Address - Zip Code:01805
Practice Address - Country:US
Practice Address - Phone:781-744-8000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-24
Last Update Date:2018-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN181913367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILK03801Medicare ID - Type Unspecified
ME000674001Medicare PIN