Provider Demographics
NPI:1780780791
Name:BINGHAM, CASSANDRA CHILD (PAC)
Entity type:Individual
Prefix:
First Name:CASSANDRA
Middle Name:CHILD
Last Name:BINGHAM
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:CASSANDRA
Other - Middle Name:C
Other - Last Name:KIMBALL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 337
Mailing Address - Street 2:
Mailing Address - City:LAYTON
Mailing Address - State:UT
Mailing Address - Zip Code:84041-0337
Mailing Address - Country:US
Mailing Address - Phone:801-773-4840
Mailing Address - Fax:801-525-8151
Practice Address - Street 1:1477 NORTH 2000 WEST
Practice Address - Street 2:WESTSIDE MEDICAL
Practice Address - City:CLINTON
Practice Address - State:UT
Practice Address - Zip Code:84015
Practice Address - Country:US
Practice Address - Phone:801-774-8888
Practice Address - Fax:801-825-8519
Is Sole Proprietor?:No
Enumeration Date:2006-09-16
Last Update Date:2020-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT3106141206363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT005519611Medicare ID - Type Unspecified
S92089Medicare UPIN