Provider Demographics
NPI:1689451916
Name:INGRAM, RICHARD TYLER (FNP)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:TYLER
Last Name:INGRAM
Suffix:
Gender:M
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2230 PARK RD STE 105
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28203-6664
Mailing Address - Country:US
Mailing Address - Phone:336-681-5438
Mailing Address - Fax:
Practice Address - Street 1:2230 PARK RD STE 105
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28203-6664
Practice Address - Country:US
Practice Address - Phone:980-221-2689
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-11
Last Update Date:2023-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5018684363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner