Healthcare Provider Details

I. General information

NPI: 1346632098
Provider Name (Legal Business Name): MARY AMANDA INGHRAM PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MARY AMANDA CLINE

II. Dates (important events)

Enumeration Date: 03/04/2015
Last Update Date: 12/08/2022
Certification Date: 12/08/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5255 LOUGHBORO RD NW
WASHINGTON DC
20016-2633
US

IV. Provider business mailing address

6201 GREENLEIGH AVE
MIDDLE RIVER MD
21220-2004
US

V. Phone/Fax

Practice location:
  • Phone: 202-537-4080
  • Fax: 202-537-4588
Mailing address:
  • Phone: 410-933-6423
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA-TF-0191
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberC06741
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: