Provider Demographics
NPI:1851512560
Name:INGRAM, JESSE JR (PA-C)
Entity Type:Individual
Prefix:MR
First Name:JESSE
Middle Name:
Last Name:INGRAM
Suffix:JR
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1033 LA MARILLO CIR
Mailing Address - Street 2:
Mailing Address - City:CORONA
Mailing Address - State:CA
Mailing Address - Zip Code:92879-8234
Mailing Address - Country:US
Mailing Address - Phone:909-427-5525
Mailing Address - Fax:909-427-7602
Practice Address - Street 1:9985 SIERRA AVE
Practice Address - Street 2:
Practice Address - City:FONTANA
Practice Address - State:CA
Practice Address - Zip Code:92335-6720
Practice Address - Country:US
Practice Address - Phone:909-427-5525
Practice Address - Fax:909-427-7602
Is Sole Proprietor?:No
Enumeration Date:2007-05-01
Last Update Date:2021-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA13419363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical