Provider Demographics
NPI:1083721518
Name:BINGHAM, RANDY DWAYNE (PA-C)
Entity Type:Individual
Prefix:MR
First Name:RANDY
Middle Name:DWAYNE
Last Name:BINGHAM
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 1:1704 JENKINS ST
Mailing Address - Street 2:
Mailing Address - City:ROCKPORT
Mailing Address - State:TX
Mailing Address - Zip Code:78382-3341
Mailing Address - Country:US
Mailing Address - Phone:361-790-9047
Mailing Address - Fax:361-790-9615
Practice Address - Street 1:1704 JENKINS ST
Practice Address - Street 2:
Practice Address - City:ROCKPORT
Practice Address - State:TX
Practice Address - Zip Code:78382-3341
Practice Address - Country:US
Practice Address - Phone:361-790-9047
Practice Address - Fax:361-790-9615
Is Sole Proprietor?:No
Enumeration Date:2006-08-23
Last Update Date:2016-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA00458363A00000X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX196053601Medicaid
TX8Y3994OtherBLUE CROSS BLUE SHIELD
TX8F8125Medicare PIN