Provider Demographics
NPI:1124079017
Name:INGRAM, MARK W (PAC)
Entity type:Individual
Prefix:MR
First Name:MARK
Middle Name:W
Last Name:INGRAM
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4519 MAJESTIC MAGNOLIA LANE
Mailing Address - Street 2:
Mailing Address - City:MORRISTOWN
Mailing Address - State:TN
Mailing Address - Zip Code:37814
Mailing Address - Country:US
Mailing Address - Phone:423-312-8546
Mailing Address - Fax:423-581-9692
Practice Address - Street 1:908 WEST NORTH 4TH ST
Practice Address - Street 2:
Practice Address - City:MORRISTOWN
Practice Address - State:TN
Practice Address - Zip Code:37813
Practice Address - Country:US
Practice Address - Phone:423-586-4995
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNPA783363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3669178Medicare ID - Type Unspecified
S83187Medicare UPIN