Provider Demographics
NPI:1356047104
Name:AMBROSE, STEPHAN T
Entity type:Individual
Prefix:
First Name:STEPHAN
Middle Name:T
Last Name:AMBROSE
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 1:5024 SW 155TH TER
Mailing Address - Street 2:
Mailing Address - City:MIRAMAR
Mailing Address - State:FL
Mailing Address - Zip Code:33027-5644
Mailing Address - Country:US
Mailing Address - Phone:754-204-4701
Mailing Address - Fax:
Practice Address - Street 1:5024 SW 155TH TER
Practice Address - Street 2:
Practice Address - City:MIRAMAR
Practice Address - State:FL
Practice Address - Zip Code:33027-5644
Practice Address - Country:US
Practice Address - Phone:754-204-4701
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-03
Last Update Date:2023-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program