Provider Demographics
NPI:1679688675
Name:INGRAM, BRENDA LEIGH (PA-C)
Entity Type:Individual
Prefix:
First Name:BRENDA
Middle Name:LEIGH
Last Name:INGRAM
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:BRENDA
Other - Middle Name:LEIGH
Other - Last Name:HALE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:PO BOX 841656
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-1656
Mailing Address - Country:US
Mailing Address - Phone:903-531-5000
Mailing Address - Fax:
Practice Address - Street 1:115 AIRPORT RD
Practice Address - Street 2:
Practice Address - City:SULPHUR SPRINGS
Practice Address - State:TX
Practice Address - Zip Code:75482-2105
Practice Address - Country:US
Practice Address - Phone:903-885-7671
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-20
Last Update Date:2017-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA03143363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXP01761904OtherRAIL ROAD MEDICARE
TX75-2616977-002OtherTRICARE
TX75-2616977-129OtherTRICARE
TX8478MAOtherBCBS
TX313744004Medicaid
TX313744006Medicaid
TX75-2616977-001OtherTRICARE
TX8479MAOtherBCBS
TXP01762486OtherRAIL ROAD MEDICARE
TX75-0818167-015OtherTRICARE
TX75-0818167-044OtherTRICARE
TX75-0818167-048OtherTRICARE
TX75-2616977-028OtherTRICARE
TX313744005Medicaid
TX75-0818167-022OtherTRICARE
TX75-1976930-005OtherTRICARE
TX313744007Medicaid
TXP01761904OtherRAIL ROAD MEDICARE
P62954Medicare UPIN
TXP01762486OtherRAIL ROAD MEDICARE
TX75-0818167-048OtherTRICARE
TX75-0818167-015OtherTRICARE