Provider Demographics
NPI:1396576732
Name:INGRAM, MOLLY SMITH (PA)
Entity type:Individual
Prefix:MRS
First Name:MOLLY
Middle Name:SMITH
Last Name:INGRAM
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:516 MARTIN LN
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30909-3406
Mailing Address - Country:US
Mailing Address - Phone:478-365-1215
Mailing Address - Fax:
Practice Address - Street 1:1331 APPLING HARLEM RD
Practice Address - Street 2:
Practice Address - City:HARLEM
Practice Address - State:GA
Practice Address - Zip Code:30814-4130
Practice Address - Country:US
Practice Address - Phone:706-556-2012
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-08
Last Update Date:2024-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA12634207Q00000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine