Healthcare Provider Details

I. General information

NPI: 1720470727
Provider Name (Legal Business Name): AMBROSIA SANTANA PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/27/2015
Last Update Date: 10/01/2020
Certification Date: 10/01/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

42404 LEEDS FIELD DR
CHANTILLY VA
20152-5966
US

IV. Provider business mailing address

42404 LEEDS FIELD DR
CHANTILLY VA
20152-5966
US

V. Phone/Fax

Practice location:
  • Phone: 571-438-9590
  • Fax:
Mailing address:
  • Phone: 571-438-9590
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0110-007505
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code156FX1101X
TaxonomyOphthalmic Assistant
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: