Basic Information
| Provider Information | |||||||||
| NPI: | 1598285751 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | EMBRADOR | ||||||||
| FirstName: | REGINA | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3170 KETTERING BLVD BLDG B3 | ||||||||
| Address2: | |||||||||
| City: | MORAINE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454391924 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9379913188 | ||||||||
| FaxNumber: | 9372239811 | ||||||||
| Practice Location | |||||||||
| Address1: | 1843 W MAIN ST | ||||||||
| Address2: | |||||||||
| City: | TROY | ||||||||
| State: | OH | ||||||||
| PostalCode: | 453732303 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9372084020 | ||||||||
| FaxNumber: | 9372084126 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/20/2017 | ||||||||
| LastUpdateDate: | 10/07/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | C0006446 | MD | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | 50.006046RX | OH | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | C0006446 | 01 | MD | MARYLAND BOARD OF PHYSICIANS | OTHER | 1141856 | 01 | NCCPA | OTHER |