Healthcare Provider Details

I. General information

NPI: 1750611216
Provider Name (Legal Business Name): BENJAMIN DAVID INGRAM PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/06/2010
Last Update Date: 01/06/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

307 BOATNER RD SUITE 114
EGLIN AFB FL
32542-1282
US

IV. Provider business mailing address

307 BOATNER RD SUITE 114
EGLIN AFB FL
32542-1282
US

V. Phone/Fax

Practice location:
  • Phone: 850-883-4677
  • Fax: 850-883-9702
Mailing address:
  • Phone: 850-883-4677
  • Fax: 850-883-9702

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: