Provider Demographics
NPI:1164534129
Name:BINGAMON, THOMAS W (PA-C)
Entity Type:Individual
Prefix:MR
First Name:THOMAS
Middle Name:W
Last Name:BINGAMON
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 1:19717 THORNLAKE AVE
Mailing Address - Street 2:
Mailing Address - City:CERRITOS
Mailing Address - State:CA
Mailing Address - Zip Code:90703-7726
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6801 PARK TER
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90045-1543
Practice Address - Country:US
Practice Address - Phone:310-665-7200
Practice Address - Fax:310-337-7630
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2022-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA15377363A00000X
CADC17017111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No111N00000XChiropractic ProvidersChiropractor