Healthcare Provider Details

I. General information

NPI: 1306198445
Provider Name (Legal Business Name): ANALISA AMBROSI PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/14/2012
Last Update Date: 10/23/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

255 W LANCASTER AVE
PAOLI PA
19301-1763
US

IV. Provider business mailing address

255 W LANCASTER AVE
PAOLI PA
19301-1763
US

V. Phone/Fax

Practice location:
  • Phone: 484-565-1510
  • Fax: 484-565-1513
Mailing address:
  • Phone: 484-565-1510
  • Fax: 484-565-1513

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberMA057006
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number016113
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: