Healthcare Provider Details

I. General information

NPI: 1750356192
Provider Name (Legal Business Name): DANIEL WAYNE INGRAM PA C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/21/2006
Last Update Date: 03/29/2021
Certification Date: 03/29/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4207 LAKE BOONE TRL
RALEIGH NC
27607
US

IV. Provider business mailing address

4207 LAKE BOONE TRL
RALEIGH NC
27607-6684
US

V. Phone/Fax

Practice location:
  • Phone: 919-785-3400
  • Fax:
Mailing address:
  • Phone: 919-784-1410
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number102777
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: