MEDICARE: ANGEL PATRICE INGRAM

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225400000X	Rehabilitation Practitioner		NV

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	050504466-02	OTHER	NV	UNITED HEALTHCARE

General Provider Information

NPI Number	:	1003241944
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ANGEL PATRICE INGRAM

Provider Business Mailing Address
First Line	:	4730 E CRAIG RD
Second Line	:	#2144
City	:	LAS VEGAS
State	:	NV
Zip	:	89115-2591
Country	:	US
Telephone Number	:	702-721-2156
Fax Number	:

Provider Business Practice Location Address
First Line	:	4730 E CRAIG RD
Second Line	:	#2144
City	:	LAS VEGAS
State	:	NV
Zip	:	89115-2591
Country	:	US
Telephone Number	:	702-721-2156
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/11/2013
Last Update Date	:	09/11/2013

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Directions to “ ANGEL PATRICE INGRAM ” Practice Location

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