Healthcare Provider Details

I. General information

NPI: 1780207449
Provider Name (Legal Business Name): NICOLE AMBROSE PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/28/2020
Last Update Date: 12/07/2022
Certification Date: 12/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1431 YOST DR
SAN DIEGO CA
92109-1347
US

IV. Provider business mailing address

1431 YOST DR
SAN DIEGO CA
92109-1347
US

V. Phone/Fax

Practice location:
  • Phone: 760-766-6809
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA59843
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberPA59843
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: