Provider Demographics
NPI:1336650712
Name:INGRAM, ELISE MARIE (PA-C)
Entity type:Individual
Prefix:
First Name:ELISE
Middle Name:MARIE
Last Name:INGRAM
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:ELISE
Other - Middle Name:MARIE
Other - Last Name:VAN PELT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1001 WEST ST
Mailing Address - Street 2:
Mailing Address - City:CARTHAGE
Mailing Address - State:NY
Mailing Address - Zip Code:13619-9776
Mailing Address - Country:US
Mailing Address - Phone:315-493-1000
Mailing Address - Fax:315-493-0105
Practice Address - Street 1:156 WILLIAM ST RM 303
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10038-5307
Practice Address - Country:US
Practice Address - Phone:888-803-3370
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-12
Last Update Date:2024-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY021853363A00000X
363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant