=====================================================
General NPI Number Information
=====================================================
NPI Number | 1972959492
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ALLYSON MICHELLE INGRAM PA-C
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/13/2016
-----------------------------------------------------
Last Update Date | 09/10/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 462 ELMA G MILES PKWY STE 102A
-----------------------------------------------------
City | HINESVILLE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31313-4000
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 912-369-9310
-----------------------------------------------------
Fax | 912-877-3102
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX K
-----------------------------------------------------
City | GOLDSBORO
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27533-9710
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 919-580-0004
-----------------------------------------------------
Fax | 919-580-9099
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number | 001006436
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number | 9473
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------