Provider Demographics
NPI:1700022613
Name:FOUGEROUSSE, AMBRE JAMARRA (PA-C)
Entity type:Individual
Prefix:
First Name:AMBRE
Middle Name:JAMARRA
Last Name:FOUGEROUSSE
Suffix:
Gender:F
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 1:218 PASADENA AVE S
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33707-1251
Mailing Address - Country:US
Mailing Address - Phone:941-961-3303
Mailing Address - Fax:
Practice Address - Street 1:3991 STONE MOUNTAIN HWY
Practice Address - Street 2:
Practice Address - City:SNELLVILLE
Practice Address - State:GA
Practice Address - Zip Code:30039-3929
Practice Address - Country:US
Practice Address - Phone:678-786-8677
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-12-23
Last Update Date:2025-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9106967363A00000X
GA5491363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant