Provider Demographics
NPI:1336277102
Name:AMBO, EDWIN G
Entity Type:Individual
Prefix:DR
First Name:EDWIN
Middle Name:G
Last Name:AMBO
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 1:1801 10TH AVE NW
Mailing Address - Street 2:
Mailing Address - City:ISSAQUAH
Mailing Address - State:WA
Mailing Address - Zip Code:98027-5384
Mailing Address - Country:US
Mailing Address - Phone:425-369-6726
Mailing Address - Fax:
Practice Address - Street 1:1801 10TH AVE NW
Practice Address - Street 2:
Practice Address - City:ISSAQUAH
Practice Address - State:WA
Practice Address - Zip Code:98027-5384
Practice Address - Country:US
Practice Address - Phone:425-369-6726
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA1804T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist