Provider Demographics
NPI:1700142122
Name:INGRASSIA, MATTHEW JAN
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:JAN
Last Name:INGRASSIA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:122 WOODLAWN AVE APT D
Mailing Address - Street 2:
Mailing Address - City:COLLINGSWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:08108
Mailing Address - Country:US
Mailing Address - Phone:732-771-6969
Mailing Address - Fax:
Practice Address - Street 1:2800 N VANCOUVER AVE
Practice Address - Street 2:SUITE 230
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97227-1630
Practice Address - Country:US
Practice Address - Phone:503-413-2901
Practice Address - Fax:503-413-4898
Is Sole Proprietor?:No
Enumeration Date:2012-04-10
Last Update Date:2020-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORDO169804207R00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine