Provider Demographics
NPI:1285229500
Name:AMBROSE, NATHAN (PA-C)
Entity type:Individual
Prefix:
First Name:NATHAN
Middle Name:
Last Name:AMBROSE
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 NE MOTHER JOSEPH PL STE 210
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98664-3295
Mailing Address - Country:US
Mailing Address - Phone:360-254-6161
Mailing Address - Fax:360-803-0847
Practice Address - Street 1:200 NE MOTHER JOSEPH PL STE 110
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98664-3293
Practice Address - Country:US
Practice Address - Phone:360-254-6161
Practice Address - Fax:360-803-0847
Is Sole Proprietor?:No
Enumeration Date:2021-03-08
Last Update Date:2024-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA61409222363AS0400X
ORPA208018363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical