Provider Demographics
NPI:1558711507
Name:AMBROSE, RYAN
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:
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 1:3318 N STONE GULLY
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85207-1163
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10750 W MCDOWELL RD
Practice Address - Street 2:BLDG A100
Practice Address - City:AVONDALE
Practice Address - State:AZ
Practice Address - Zip Code:85392-5960
Practice Address - Country:US
Practice Address - Phone:623-877-3007
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-20
Last Update Date:2016-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ2112152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ2112OtherARIZONA OPTOMETRIC LICENSING NUMBER