Provider Demographics
NPI:1598285751
Name:EMBRADOR, REGINA (PA-C)
Entity Type:Individual
Prefix:
First Name:REGINA
Middle Name:
Last Name:EMBRADOR
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 1:3170 KETTERING BLVD BLDG B3
Mailing Address - Street 2:
Mailing Address - City:MORAINE
Mailing Address - State:OH
Mailing Address - Zip Code:45439-1924
Mailing Address - Country:US
Mailing Address - Phone:937-991-3188
Mailing Address - Fax:937-223-9811
Practice Address - Street 1:1843 W MAIN ST
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:OH
Practice Address - Zip Code:45373-2303
Practice Address - Country:US
Practice Address - Phone:937-208-4020
Practice Address - Fax:937-208-4126
Is Sole Proprietor?:No
Enumeration Date:2017-06-20
Last Update Date:2019-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC0006446363A00000X
OH50.006046RX363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDC0006446OtherMARYLAND BOARD OF PHYSICIANS
1141856OtherNCCPA