Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 2081P2900X | Pain Medicine | A108622 | CA |
NPI | 1083769566 |
---|---|
Provider Name | Mary Antoniette Ambach |
First Address | Carlsbad, CA 92011-1113 |
Second Address | Carlsbad, CA 92011 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 24/01/2007 |
Last Update Date | 17/04/2019 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
00231 | BCBS (01) | FL |
1083769566 | CIGNA (01) | FL |
I70854 | (02) | FL |