Healthcare Provider Details

I. General information

NPI: 1962326330
Provider Name (Legal Business Name): SAMUEL INGRAM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/07/2026
Last Update Date: 08/07/2026
Certification Date: 08/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

125A LITTON HTS
SCOTT DEPOT WV
25560-9741
US

IV. Provider business mailing address

125A LITTON HTS
SCOTT DEPOT WV
25560-9741
US

V. Phone/Fax

Practice location:
  • Phone: 304-553-5760
  • Fax:
Mailing address:
  • Phone: 304-553-5760
  • Fax:

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: