Provider Demographics
NPI:1194024299
Name:MCDONALD, AMBER EBONI FATIMA (PA)
Entity type:Individual
Prefix:MRS
First Name:AMBER
Middle Name:EBONI FATIMA
Last Name:MCDONALD
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 HIGH RIDGE PARK
Mailing Address - Street 2:FL 2
Mailing Address - City:STAMFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06905-1332
Mailing Address - Country:US
Mailing Address - Phone:203-869-1145
Mailing Address - Fax:203-618-1721
Practice Address - Street 1:6 GREENWICH OFFICE PARK
Practice Address - Street 2:
Practice Address - City:GREENWICH
Practice Address - State:CT
Practice Address - Zip Code:06831-5151
Practice Address - Country:US
Practice Address - Phone:203-869-1145
Practice Address - Fax:203-618-1721
Is Sole Proprietor?:No
Enumeration Date:2011-03-15
Last Update Date:2024-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9105797363A00000X
NH1079363A00000X
NY014676363AS0400X
CT5523363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH3101563Medicaid
NH3101563Medicaid