Provider Demographics
NPI:1073044038
Name:INGRAM, AMANDA RAE (MD)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:RAE
Last Name:INGRAM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:R
Other - Last Name:HARRELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 68
Mailing Address - Street 2:
Mailing Address - City:POLLOCKSVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28573-0068
Mailing Address - Country:US
Mailing Address - Phone:252-633-2712
Mailing Address - Fax:252-633-5418
Practice Address - Street 1:705 NEWMAN RD
Practice Address - Street 2:
Practice Address - City:NEW BERN
Practice Address - State:NC
Practice Address - Zip Code:28562-5239
Practice Address - Country:US
Practice Address - Phone:252-633-2712
Practice Address - Fax:252-633-5418
Is Sole Proprietor?:No
Enumeration Date:2017-03-22
Last Update Date:2022-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NC2022-01723208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program