Provider Demographics
NPI:1821216722
Name:BALLINGHAM, DAVID JAY (PAC)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:JAY
Last Name:BALLINGHAM
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 1:126 W. BERRY BLOSSOM LN
Mailing Address - Street 2:
Mailing Address - City:GARDEN CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84028
Mailing Address - Country:US
Mailing Address - Phone:439-946-3660
Mailing Address - Fax:
Practice Address - Street 1:811 N HARRISVILLE RD
Practice Address - Street 2:
Practice Address - City:HARRISVILLE
Practice Address - State:UT
Practice Address - Zip Code:84404-3537
Practice Address - Country:US
Practice Address - Phone:801-399-1818
Practice Address - Fax:801-782-8412
Is Sole Proprietor?:No
Enumeration Date:2007-04-23
Last Update Date:2023-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT357006-3102363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant