Provider Demographics
NPI:1598008419
Name:INGRAM, ANNE (PA-C)
Entity Type:Individual
Prefix:
First Name:ANNE
Middle Name:
Last Name:INGRAM
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:ANNE
Other - Middle Name:
Other - Last Name:BRANCH
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PA
Mailing Address - Street 1:3340 E GOLDSTONE WAY
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-1026
Mailing Address - Country:US
Mailing Address - Phone:208-452-8000
Mailing Address - Fax:208-452-8055
Practice Address - Street 1:910 NW 16TH STREET
Practice Address - Street 2:STE 101
Practice Address - City:FRUITLAND
Practice Address - State:ID
Practice Address - Zip Code:83619
Practice Address - Country:US
Practice Address - Phone:208-452-8000
Practice Address - Fax:208-452-8055
Is Sole Proprietor?:No
Enumeration Date:2013-03-28
Last Update Date:2016-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID1031363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant