MEDICARE: MR. PHILLIP RANDALL INGRAM PAC

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	PA10002587	WA

General Provider Information

NPI Number	:	1942262589
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. PHILLIP RANDALL INGRAM PAC

Provider Business Mailing Address
First Line	:	16809 88TH STREET KPS
Second Line	:
City	:	LONGBRANCH
State	:	WA
Zip	:	98351-9521
Country	:	US
Telephone Number	:	253-884-4315
Fax Number	:

Provider Business Practice Location Address
First Line	:	9600 VETERANS DR SW
Second Line	:
City	:	TACOMA
State	:	WA
Zip	:	98493-0003
Country	:	US
Telephone Number	:	253-582-8440
Fax Number	:

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

Provider Enumeration Date	:	04/06/2006
Last Update Date	:	07/08/2007

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