Healthcare Provider Details

I. General information

NPI: 1245260835
Provider Name (Legal Business Name): STEPHEN D'AMBROSIO MPAS, PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/03/2006
Last Update Date: 07/05/2023
Certification Date: 06/14/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 ELMWOOD AVE
ROCHESTER NY
14642-2665
US

IV. Provider business mailing address

601 ELMWOOD AVE BOX 648
ROCHESTER NY
14642-0001
US

V. Phone/Fax

Practice location:
  • Phone: 585-275-1839
  • Fax: 585-473-4861
Mailing address:
  • Phone: 585-275-2734
  • Fax: 585-273-1033

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number6493
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number006493
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: