Provider Demographics
NPI:1497229462
Name:AMBROSE, THOMAS RYAN
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:RYAN
Last Name:AMBROSE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4338 N WOODLAWN CT
Mailing Address - Street 2:
Mailing Address - City:BEL AIRE
Mailing Address - State:KS
Mailing Address - Zip Code:67220-3850
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:929 N SAINT FRANCIS ST
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67214-3821
Practice Address - Country:US
Practice Address - Phone:316-268-8200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-14
Last Update Date:2019-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS11-05355225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist