Provider Demographics
NPI:1720470727
Name:SANTANA, AMBROSIA (PA-C)
Entity Type:Individual
Prefix:
First Name:AMBROSIA
Middle Name:
Last Name:SANTANA
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:42404 LEEDS FIELD DR
Mailing Address - Street 2:
Mailing Address - City:CHANTILLY
Mailing Address - State:VA
Mailing Address - Zip Code:20152-5966
Mailing Address - Country:US
Mailing Address - Phone:571-438-9590
Mailing Address - Fax:
Practice Address - Street 1:42404 LEEDS FIELD DR
Practice Address - Street 2:
Practice Address - City:CHANTILLY
Practice Address - State:VA
Practice Address - Zip Code:20152-5966
Practice Address - Country:US
Practice Address - Phone:571-438-9590
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-02-27
Last Update Date:2020-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
156FX1101X, 390200000X
VA0110-007505363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No156FX1101XEye and Vision Services ProvidersTechnician/TechnologistOphthalmic Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program