Provider Demographics
NPI:1437119112
Name:INGRAM, PAULETTE KEITH (MD)
Entity Type:Individual
Prefix:
First Name:PAULETTE
Middle Name:KEITH
Last Name:INGRAM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:529 BECKER DR
Mailing Address - Street 2:
Mailing Address - City:ROANOKE RAPIDS
Mailing Address - State:NC
Mailing Address - Zip Code:27870-3303
Mailing Address - Country:US
Mailing Address - Phone:252-537-1400
Mailing Address - Fax:252-537-4936
Practice Address - Street 1:529 BECKER DR
Practice Address - Street 2:
Practice Address - City:ROANOKE RAPIDS
Practice Address - State:NC
Practice Address - Zip Code:27870-3303
Practice Address - Country:US
Practice Address - Phone:252-537-1400
Practice Address - Fax:252-537-4936
Is Sole Proprietor?:No
Enumeration Date:2006-03-25
Last Update Date:2012-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC28419208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8945264Medicaid
NCF45889Medicare UPIN
NC8945264Medicaid