Provider Demographics
NPI:1700167418
Name:BINGHAM, KELSY ANN (PA-C)
Entity Type:Individual
Prefix:
First Name:KELSY
Middle Name:ANN
Last Name:BINGHAM
Suffix:
Gender:F
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:PO BOX 27128
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84127-0128
Mailing Address - Country:US
Mailing Address - Phone:801-387-3400
Mailing Address - Fax:801-475-1621
Practice Address - Street 1:4403 HARRISON BLVD
Practice Address - Street 2:SUITE 3815
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84403-3271
Practice Address - Country:US
Practice Address - Phone:801-387-3400
Practice Address - Fax:801-475-1621
Is Sole Proprietor?:No
Enumeration Date:2011-09-08
Last Update Date:2012-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5722982-1206363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant