Provider Demographics
NPI:1134257876
Name:BINGHAM, MEL (PA-C)
Entity type:Individual
Prefix:
First Name:MEL
Middle Name:
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 1:220 BANNOCK ST
Mailing Address - Street 2:
Mailing Address - City:MALAD CITY
Mailing Address - State:ID
Mailing Address - Zip Code:83252-5068
Mailing Address - Country:US
Mailing Address - Phone:208-766-2600
Mailing Address - Fax:208-766-4258
Practice Address - Street 1:220 BANNOCK ST
Practice Address - Street 2:
Practice Address - City:MALAD CITY
Practice Address - State:ID
Practice Address - Zip Code:83252-5068
Practice Address - Country:US
Practice Address - Phone:208-766-2600
Practice Address - Fax:208-766-4258
Is Sole Proprietor?:No
Enumeration Date:2007-03-02
Last Update Date:2015-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK757363A00000X
IDPA-1173363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK8EE023Medicare PIN