Provider Demographics
NPI:1366415283
Name:INGRAM, WILLIAM (PA-C)
Entity type:Individual
Prefix:MR
First Name:WILLIAM
Middle Name:
Last Name:INGRAM
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9776 OLDE GEORGETOWN
Mailing Address - Street 2:
Mailing Address - City:CENTERVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:45458-6103
Mailing Address - Country:US
Mailing Address - Phone:937-938-8187
Mailing Address - Fax:
Practice Address - Street 1:1130 S MAIN ST
Practice Address - Street 2:
Practice Address - City:ENGLEWOOD
Practice Address - State:OH
Practice Address - Zip Code:45322-2819
Practice Address - Country:US
Practice Address - Phone:937-208-6879
Practice Address - Fax:937-208-6886
Is Sole Proprietor?:No
Enumeration Date:2006-02-10
Last Update Date:2025-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
FLPA9104087363A00000X
IN10002420A363A00000X
OH50.002024RX363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0094916Medicaid
FL261843500Medicaid