Provider Demographics
NPI:1679760755
Name:INGRAO, SUZANNE AMALIE (MD)
Entity Type:Individual
Prefix:
First Name:SUZANNE
Middle Name:AMALIE
Last Name:INGRAO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:SUZANNE
Other - Middle Name:AMALIE
Other - Last Name:POPP
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:407 14TH AVE SE
Mailing Address - Street 2:
Mailing Address - City:PUYALLUP
Mailing Address - State:WA
Mailing Address - Zip Code:98372-3770
Mailing Address - Country:US
Mailing Address - Phone:253-597-4626
Mailing Address - Fax:
Practice Address - Street 1:407 14TH AVE SE
Practice Address - Street 2:
Practice Address - City:PUYALLUP
Practice Address - State:WA
Practice Address - Zip Code:98372-3770
Practice Address - Country:US
Practice Address - Phone:253-597-4626
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-02
Last Update Date:2011-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA00049333208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics