Healthcare Provider Details

I. General information

NPI: 1134100498
Provider Name (Legal Business Name): PATRICK A AMBIEL PA
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 11/11/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1960 NW 167TH PL
BEAVERTON OR
97006-4804
US

IV. Provider business mailing address

275 MCCLURE AVE
ASTORIA OR
97103-5514
US

V. Phone/Fax

Practice location:
  • Phone: 503-629-7500
  • Fax: 503-629-7505
Mailing address:
  • Phone: 503-368-5286
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA00045
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: