MEDICARE: REX AMBATALI JR. AGACNP-BC, FNP-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	95001863	CA
2	363LA2100X	Acute Care Nurse Practitioner	95001863	CA

General Provider Information

NPI Number	:	1013308485
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	REX AMBATALI JR. AGACNP-BC, FNP-C

Provider Business Mailing Address
First Line	:	4301 X ST
Second Line	:
City	:	SACRAMENTO
State	:	CA
Zip	:	95817-2214
Country	:	US
Telephone Number	:	916-734-7463
Fax Number	:

Provider Business Practice Location Address
First Line	:	2633 PACIFIC AVE
Second Line	:
City	:	STOCKTON
State	:	CA
Zip	:	95204-4429
Country	:	US
Telephone Number	:	209-944-5530
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/06/2015
Last Update Date	:	05/14/2025

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