Provider Demographics
NPI:1730313354
Name:ISSA, AMBER B (AA)
Entity Type:Individual
Prefix:
First Name:AMBER
Middle Name:B
Last Name:ISSA
Suffix:
Gender:F
Credentials:AA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3100 SPRING FOREST RD
Mailing Address - Street 2:SUITE 130
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27616-2880
Mailing Address - Country:US
Mailing Address - Phone:919-882-0795
Mailing Address - Fax:
Practice Address - Street 1:2308 WESVILL CT
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27607-2949
Practice Address - Country:US
Practice Address - Phone:919-781-4311
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-05-11
Last Update Date:2015-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA005658367H00000X
NC1000-00571367H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367H00000XPhysician Assistants & Advanced Practice Nursing ProvidersAnesthesiologist Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA219822143AMedicaid
GA202I326072Medicare PIN