Provider Demographics
NPI:1487271045
Name:INGALLS, GRANT (MPAS)
Entity type:Individual
Prefix:
First Name:GRANT
Middle Name:
Last Name:INGALLS
Suffix:
Gender:M
Credentials:MPAS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:640 KOLTER DR
Mailing Address - Street 2:
Mailing Address - City:INDIANA
Mailing Address - State:PA
Mailing Address - Zip Code:15701-3570
Mailing Address - Country:US
Mailing Address - Phone:724-427-2762
Mailing Address - Fax:724-427-2707
Practice Address - Street 1:120 IRMC DR STE 100
Practice Address - Street 2:
Practice Address - City:INDIANA
Practice Address - State:PA
Practice Address - Zip Code:15701-3674
Practice Address - Country:US
Practice Address - Phone:724-427-2707
Practice Address - Fax:724-427-2707
Is Sole Proprietor?:No
Enumeration Date:2020-06-30
Last Update Date:2024-01-03
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
PAMA061593363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant