Provider Demographics
NPI:1376547935
Name:BINGHAM, DALE JAMES (PA-C)
Entity Type:Individual
Prefix:
First Name:DALE
Middle Name:JAMES
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 1:740 S WOODRUFF AVE
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83401-5285
Mailing Address - Country:US
Mailing Address - Phone:208-542-9111
Mailing Address - Fax:208-542-9114
Practice Address - Street 1:630 E 1400 N STE 150
Practice Address - Street 2:
Practice Address - City:LOGAN
Practice Address - State:UT
Practice Address - Zip Code:84341-2549
Practice Address - Country:US
Practice Address - Phone:435-915-4465
Practice Address - Fax:435-799-3664
Is Sole Proprietor?:No
Enumeration Date:2005-06-10
Last Update Date:2023-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPA-2487363A00000X
UT5042433-1206363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXQ01074Medicare UPIN