Provider Demographics
NPI:1508361361
Name:INGRAM, MARIAN (PHYSICIAN ASSISTANT)
Entity Type:Individual
Prefix:
First Name:MARIAN
Middle Name:
Last Name:INGRAM
Suffix:
Gender:F
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:MARIAN
Other - Middle Name:JOSE
Other - Last Name:RODRIGUEZ GUTIERREZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:350 NW 84TH AVE STE 102
Mailing Address - Street 2:
Mailing Address - City:PLANTATION
Mailing Address - State:FL
Mailing Address - Zip Code:33324-1820
Mailing Address - Country:US
Mailing Address - Phone:954-370-7555
Mailing Address - Fax:
Practice Address - Street 1:350 NW 84TH AVE STE 102
Practice Address - Street 2:
Practice Address - City:PLANTATION
Practice Address - State:FL
Practice Address - Zip Code:33324-1820
Practice Address - Country:US
Practice Address - Phone:954-370-7555
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-26
Last Update Date:2021-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9111067363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant