Provider Demographics
NPI:1245539659
Name:PANICO, AMBROSE FRANCIS (DO)
Entity type:Individual
Prefix:DR
First Name:AMBROSE
Middle Name:FRANCIS
Last Name:PANICO
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:6116 E ARBOR AVE STE 112
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85206-6103
Mailing Address - Country:US
Mailing Address - Phone:480-641-5400
Mailing Address - Fax:480-218-4353
Practice Address - Street 1:6116 E ARBOR AVE STE 112
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85206-6103
Practice Address - Country:US
Practice Address - Phone:480-641-5400
Practice Address - Fax:480-218-4353
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-24
Last Update Date:2020-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ008452207RC0000X, 207RC0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0001XAllopathic & Osteopathic PhysiciansInternal MedicineClinical Cardiac ElectrophysiologyGroup - Single Specialty
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ007236Medicaid