Individual
MARK AMBROSE
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
PA-C
Contact information
Practice address
3330 W 177TH ST, SUITE 3E, HAZEL CREST, IL 60429-2184
(708) 206-0010
(708) 206-0020
Mailing address
16450 104TH AVE, STE 101, ORLAND PARK, IL 60467-5416
(708) 206-0010
(708) 206-0020
Taxonomy
Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
Primary
085000830
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
K18310SC
PROVIDER NO.
IL
Enumeration date
05/10/2007
Last updated
05/13/2016
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