Provider Demographics
NPI:1942262589
Name:INGRAM, PHILLIP RANDALL (PAC)
Entity Type:Individual
Prefix:MR
First Name:PHILLIP
Middle Name:RANDALL
Last Name:INGRAM
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16809 88TH STREET KPS
Mailing Address - Street 2:
Mailing Address - City:LONGBRANCH
Mailing Address - State:WA
Mailing Address - Zip Code:98351-9521
Mailing Address - Country:US
Mailing Address - Phone:253-884-4315
Mailing Address - Fax:
Practice Address - Street 1:9600 VETERANS DR SW
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98493-0003
Practice Address - Country:US
Practice Address - Phone:253-582-8440
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA10002587363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical