Provider Demographics
NPI:1013308485
Name:AMBATALI JR., REX (AGACNP-BC, FNP-C)
Entity type:Individual
Prefix:
First Name:REX
Middle Name:
Last Name:AMBATALI JR.
Suffix:
Gender:M
Credentials:AGACNP-BC, FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4301 X ST
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95817-2214
Mailing Address - Country:US
Mailing Address - Phone:916-734-7463
Mailing Address - Fax:
Practice Address - Street 1:2633 PACIFIC AVE
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95204-4429
Practice Address - Country:US
Practice Address - Phone:209-944-5530
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-02-06
Last Update Date:2025-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95001863363LF0000X, 363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily