Provider Demographics
NPI:1700368495
Name:INGRAM, BRIAN R (PA)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:R
Last Name:INGRAM
Suffix:
Gender:M
Credentials:PA
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Mailing Address - Street 1:12127B HWY 14 N STE 5
Mailing Address - Street 2:
Mailing Address - City:CEDAR CREST
Mailing Address - State:NM
Mailing Address - Zip Code:87008-9499
Mailing Address - Country:US
Mailing Address - Phone:505-281-5180
Mailing Address - Fax:505-281-5320
Practice Address - Street 1:1851 OLD HWY 66
Practice Address - Street 2:
Practice Address - City:EDGEWOOD
Practice Address - State:NM
Practice Address - Zip Code:87015
Practice Address - Country:US
Practice Address - Phone:505-286-2396
Practice Address - Fax:505-286-2398
Is Sole Proprietor?:No
Enumeration Date:2018-08-30
Last Update Date:2018-08-30
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NMPA2018-0050363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant