Provider Demographics
NPI:1073875126
Name:BADHAM, DAVID L (PAC)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:L
Last Name:BADHAM
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:557 W 2600 S
Mailing Address - Street 2:
Mailing Address - City:BOUNTIFUL
Mailing Address - State:UT
Mailing Address - Zip Code:84010-7717
Mailing Address - Country:US
Mailing Address - Phone:801-296-5805
Mailing Address - Fax:801-298-9156
Practice Address - Street 1:557 W 2600 S
Practice Address - Street 2:
Practice Address - City:BOUNTIFUL
Practice Address - State:UT
Practice Address - Zip Code:84010-7717
Practice Address - Country:US
Practice Address - Phone:801-296-5805
Practice Address - Fax:801-298-9156
Is Sole Proprietor?:No
Enumeration Date:2012-06-14
Last Update Date:2013-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT100964-1206363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant