Healthcare Provider Details

I. General information

NPI: 1326694076
Provider Name (Legal Business Name): NATHAN J AMBROSE PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/16/2019
Last Update Date: 03/07/2023
Certification Date: 11/09/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5000 AMBASSADOR CAFFERY PKWY STE A
LAFAYETTE LA
70508-6984
US

IV. Provider business mailing address

1132 GATHER DR
LAWRENCEVILLE GA
30043-7549
US

V. Phone/Fax

Practice location:
  • Phone: 337-470-3580
  • Fax: 337-470-3586
Mailing address:
  • Phone: 810-625-4218
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number324792
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: