Provider Demographics
NPI:1477126357
Name:INGRAHAM, WADE
Entity Type:Individual
Prefix:
First Name:WADE
Middle Name:
Last Name:INGRAHAM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:519 ALTAMONT AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT ALBANS
Mailing Address - State:WV
Mailing Address - Zip Code:25177-1840
Mailing Address - Country:US
Mailing Address - Phone:304-437-5595
Mailing Address - Fax:
Practice Address - Street 1:519 ALTAMONT AVE
Practice Address - Street 2:
Practice Address - City:SAINT ALBANS
Practice Address - State:WV
Practice Address - Zip Code:25177-1840
Practice Address - Country:US
Practice Address - Phone:304-437-5595
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-20
Last Update Date:2021-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker