Provider Demographics
NPI:1750611216
Name:INGRAM, BENJAMIN DAVID (PA)
Entity type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:DAVID
Last Name:INGRAM
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:307 BOATNER RD
Mailing Address - Street 2:SUITE 114
Mailing Address - City:EGLIN AFB
Mailing Address - State:FL
Mailing Address - Zip Code:32542-1282
Mailing Address - Country:US
Mailing Address - Phone:850-883-4677
Mailing Address - Fax:850-883-9702
Practice Address - Street 1:307 BOATNER RD
Practice Address - Street 2:SUITE 114
Practice Address - City:EGLIN AFB
Practice Address - State:FL
Practice Address - Zip Code:32542-1282
Practice Address - Country:US
Practice Address - Phone:850-883-4677
Practice Address - Fax:850-883-9702
Is Sole Proprietor?:No
Enumeration Date:2010-01-06
Last Update Date:2010-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant