Provider Demographics
NPI:1336452358
Name:INGRAM, CARLIE MARGARET (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:CARLIE
Middle Name:MARGARET
Last Name:INGRAM
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MS
Other - First Name:CARLIE
Other - Middle Name:MARGARET
Other - Last Name:BRIGHAM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:60 COMMERCIAL ST STE 404
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:NH
Mailing Address - Zip Code:03301-5096
Mailing Address - Country:US
Mailing Address - Phone:603-228-1763
Mailing Address - Fax:603-227-7539
Practice Address - Street 1:60 COMMERCIAL ST STE 404
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:NH
Practice Address - Zip Code:03301-5096
Practice Address - Country:US
Practice Address - Phone:603-228-1763
Practice Address - Fax:603-227-7539
Is Sole Proprietor?:No
Enumeration Date:2010-07-19
Last Update Date:2022-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH0791363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH30338401Medicaid
NH30338401Medicaid