Healthcare Provider Details

I. General information

NPI: 1700368495
Provider Name (Legal Business Name): BRIAN R INGRAM PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/30/2018
Last Update Date: 08/30/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1851 OLD HWY 66
EDGEWOOD NM
87015
US

IV. Provider business mailing address

12127B HWY 14 N STE 5
CEDAR CREST NM
87008-9499
US

V. Phone/Fax

Practice location:
  • Phone: 505-286-2396
  • Fax: 505-286-2398
Mailing address:
  • Phone: 505-281-5180
  • Fax: 505-281-5320

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA2018-0050
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: