Provider Demographics
NPI:1952463069
Name:BINGHAM, BRENT LYMAN (DO)
Entity Type:Individual
Prefix:DR
First Name:BRENT
Middle Name:LYMAN
Last Name:BINGHAM
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 851
Mailing Address - Street 2:
Mailing Address - City:SUNNYSIDE
Mailing Address - State:WA
Mailing Address - Zip Code:98944-0851
Mailing Address - Country:US
Mailing Address - Phone:509-837-8655
Mailing Address - Fax:509-837-3750
Practice Address - Street 1:803 E LINCOLN AVE STE E
Practice Address - Street 2:
Practice Address - City:SUNNYSIDE
Practice Address - State:WA
Practice Address - Zip Code:98944-2383
Practice Address - Country:US
Practice Address - Phone:509-837-8655
Practice Address - Fax:509-837-3750
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOP00000947207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA18529OtherL&I
WA1941103Medicaid
WA000119021Medicare ID - Type Unspecified
WA1941103Medicaid