Provider Demographics
NPI:1669016200
Name:INGRAM, MARTHA (PA-C)
Entity Type:Individual
Prefix:
First Name:MARTHA
Middle Name:
Last Name:INGRAM
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:244 MEDSPRING DR
Mailing Address - Street 2:
Mailing Address - City:CLAYTON
Mailing Address - State:NC
Mailing Address - Zip Code:27520-9293
Mailing Address - Country:US
Mailing Address - Phone:919-889-4652
Mailing Address - Fax:
Practice Address - Street 1:244 MEDSPRING DR
Practice Address - Street 2:
Practice Address - City:CLAYTON
Practice Address - State:NC
Practice Address - Zip Code:27520-9293
Practice Address - Country:US
Practice Address - Phone:919-359-0291
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-06
Last Update Date:2021-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-09587363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant