Provider Demographics
NPI:1972369528
Name:LLANES, INGRID (PHYSICIAN ASSISTANT)
Entity Type:Individual
Prefix:
First Name:INGRID
Middle Name:
Last Name:LLANES
Suffix:
Gender:F
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 34
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:SC
Mailing Address - Zip Code:29325-0034
Mailing Address - Country:US
Mailing Address - Phone:334-560-3517
Mailing Address - Fax:
Practice Address - Street 1:101 JACOBS HWY
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:SC
Practice Address - Zip Code:29325-7276
Practice Address - Country:US
Practice Address - Phone:334-560-3517
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-22
Last Update Date:2024-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC5203363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical