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General NPI Number Information
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NPI Number | 1124079017
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Entity Type | Individual
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Provider Name | MARK W INGRAM PAC
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Gender | Male
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Dates
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Enumeration Date | 05/15/2006
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 908 WEST NORTH 4TH ST
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City | MORRISTOWN
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State | TN
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Zip | 37813
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Country | US
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Telephone | 423-586-4995
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Fax |
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Provider Business Mailing Address
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Address Line | 4519 MAJESTIC MAGNOLIA LANE
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City | MORRISTOWN
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State | TN
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Zip | 37814
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Country | US
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Telephone | 423-312-8546
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Fax | 423-581-9692
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | PA783
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License Number State | TN
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