Provider Demographics
NPI:1588276836
Name:INGRAM, COBURN G
Entity type:Individual
Prefix:
First Name:COBURN
Middle Name:G
Last Name:INGRAM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:52 ENGH RD UNIT 30
Mailing Address - Street 2:
Mailing Address - City:OMAK
Mailing Address - State:WA
Mailing Address - Zip Code:98841-9646
Mailing Address - Country:US
Mailing Address - Phone:509-429-0949
Mailing Address - Fax:
Practice Address - Street 1:52 ENGH RD UNIT 30
Practice Address - Street 2:
Practice Address - City:OMAK
Practice Address - State:WA
Practice Address - Zip Code:98841-9646
Practice Address - Country:US
Practice Address - Phone:509-429-0949
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-18
Last Update Date:2020-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMC12530171R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171R00000XOther Service ProvidersInterpreter
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0303065OtherL&I PROVIDER NUMBER