Provider Demographics
NPI:1962659482
Name:INGOLD, BRUCE DAVID (PA-C)
Entity Type:Individual
Prefix:MR
First Name:BRUCE
Middle Name:DAVID
Last Name:INGOLD
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1838 HOLLAND RD
Mailing Address - Street 2:
Mailing Address - City:CATAULA
Mailing Address - State:GA
Mailing Address - Zip Code:31804-3412
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:30TH AG RECEPTION BUILDING 3020
Practice Address - Street 2:
Practice Address - City:FORT BENNING
Practice Address - State:GA
Practice Address - Zip Code:31905
Practice Address - Country:US
Practice Address - Phone:706-544-8127
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-27
Last Update Date:2008-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant