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NPI Code Detail

MEDICARE: VICTORIA FAYTH INGRAM PA-C

MEDICARE: VICTORIA FAYTH INGRAM PA-C
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
1390200000XStudent in an Organized Health Care Education/Training ProgramTN
2363A00000XPhysician AssistantIL

General Provider Information

NPI Number : 1639915713
Entity Type Code : Individual
Provider Name (Legal Business Name) : VICTORIA FAYTH INGRAM PA-C
Provider Business Mailing Address
First Line : 5 BARBARA CT
Second Line :
City : SPRINGFIELD
State : IL
Zip : 62704-4949
Country : US
Telephone Number : 314-608-1280
Fax Number :
Provider Business Practice Location Address
First Line : 1203 W AUGUSTA BLVD STE 1
Second Line :
City : CHICAGO
State : IL
Zip : 60642-4327
Country : US
Telephone Number : 773-248-2255
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 07/08/2024
Last Update Date : 02/02/2026

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Directions to “ VICTORIA FAYTH INGRAM PA-C” Practice Location

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