MEDICARE: SAMANTHA KATHRYN 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	363AM0700X	Medical Physician Assistant	TC001	KY
2	390200000X	Student in an Organized Health Care Education/Training Program
3	363A00000X	Physician Assistant	TC001	KY
4	363AS0400X	Surgical Physician Assistant	TC001	KY

General Provider Information

NPI Number	:	1164316626
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SAMANTHA KATHRYN INGRAM

Provider Business Mailing Address
First Line	:	900 SOUTH LIMESTONE STREET SUITE 205
Second Line	:
City	:	LEXINGTON
State	:	KY
Zip	:	40536-0001
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	900 SOUTH LIMESTONE STREET SUITE 205
Second Line	:
City	:	LEXINGTON
State	:	KY
Zip	:	40536-0001
Country	:	US
Telephone Number	:	859-323-1100
Fax Number	:

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

Provider Enumeration Date	:	06/06/2025
Last Update Date	:	05/08/2026

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