Basic Information
| Provider Information | |||||||||
| NPI: | 1700142122 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | INGRASSIA | ||||||||
| FirstName: | MATTHEW | ||||||||
| MiddleName: | JAN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 122 WOODLAWN AVE APT D | ||||||||
| Address2: | |||||||||
| City: | COLLINGSWOOD | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 08108 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7327716969 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2800 N VANCOUVER AVE | ||||||||
| Address2: | SUITE 230 | ||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972271630 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5034132901 | ||||||||
| FaxNumber: | 5034134898 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/10/2012 | ||||||||
| LastUpdateDate: | 06/04/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/04/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | DO169804 | OR | N | Allopathic & Osteopathic Physicians | Internal Medicine | 390200000X | Y | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.