Healthcare Provider Details

I. General information

NPI: 1093377194
Provider Name (Legal Business Name): DR. SHAUN INGRAM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/28/2019
Last Update Date: 08/09/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4250 FARONIA RD STE 4
MEMPHIS TN
38116-6527
US

IV. Provider business mailing address

4250 FARONIA RD STE 4
MEMPHIS TN
38116-6527
US

V. Phone/Fax

Practice location:
  • Phone: 901-348-9600
  • Fax:
Mailing address:
  • Phone: 901-348-9600
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number25901
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: