Provider Demographics
NPI:1144290321
Name:INGRAM, BRADLEY (PAC)
Entity type:Individual
Prefix:
First Name:BRADLEY
Middle Name:
Last Name:INGRAM
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:11110 MEDICAL CAMPUS RD
Mailing Address - Street 2:SUITE 229
Mailing Address - City:HAGERSTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:21742-6700
Mailing Address - Country:US
Mailing Address - Phone:301-665-4526
Mailing Address - Fax:301-665-4521
Practice Address - Street 1:22911 JEFFERSON BLVD
Practice Address - Street 2:
Practice Address - City:SMITHSBURG
Practice Address - State:MD
Practice Address - Zip Code:21783-1617
Practice Address - Country:US
Practice Address - Phone:301-824-3343
Practice Address - Fax:301-824-6323
Is Sole Proprietor?:No
Enumeration Date:2006-01-23
Last Update Date:2023-03-07
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
VA0110001879363AM0700X
MDC0003519363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAMI5599329OtherVA-DEA