Provider Demographics
NPI:1770131104
Name:BINGHAM, KENNETH BROOKE (PA)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:BROOKE
Last Name:BINGHAM
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4600 ROSWELL RD UNIT 515
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30342-3091
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:100 THREE RIVERS DR NE STE A
Practice Address - Street 2:
Practice Address - City:ROME
Practice Address - State:GA
Practice Address - Zip Code:30161-4999
Practice Address - Country:US
Practice Address - Phone:709-292-0040
Practice Address - Fax:706-378-0556
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-28
Last Update Date:2019-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA9270363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical