Healthcare Provider Details

I. General information

NPI: 1154628105
Provider Name (Legal Business Name): JOEL PAUL AMBROSIO PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/26/2011
Last Update Date: 07/07/2020
Certification Date: 07/07/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 29TH ST SUITE 501
OAKLAND CA
94609-3522
US

IV. Provider business mailing address

400 29TH ST SUITE 501
OAKLAND CA
94609-3522
US

V. Phone/Fax

Practice location:
  • Phone: 510-268-1800
  • Fax: 510-268-1803
Mailing address:
  • Phone: 510-268-1800
  • Fax: 510-268-1803

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA21498
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: