Healthcare Provider Details

I. General information

NPI: 1285229500
Provider Name (Legal Business Name): NATHAN AMBROSE PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/08/2021
Last Update Date: 10/30/2024
Certification Date: 10/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 NE MOTHER JOSEPH PL STE 110
VANCOUVER WA
98664-3293
US

IV. Provider business mailing address

200 NE MOTHER JOSEPH PL STE 210
VANCOUVER WA
98664-3295
US

V. Phone/Fax

Practice location:
  • Phone: 360-254-6161
  • Fax: 360-803-0847
Mailing address:
  • Phone: 360-254-6161
  • Fax: 360-803-0847

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA208018
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberPA61409222
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: