Provider Demographics
NPI:1548779713
Name:BINGHAM, RYAN KIRK (PA)
Entity type:Individual
Prefix:
First Name:RYAN
Middle Name:KIRK
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 1:2855 E BROWN RD STE 28
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85213-4217
Mailing Address - Country:US
Mailing Address - Phone:480-625-4538
Mailing Address - Fax:480-625-4561
Practice Address - Street 1:2855 E BROWN RD STE 28
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85213-4217
Practice Address - Country:US
Practice Address - Phone:480-625-4538
Practice Address - Fax:480-625-4561
Is Sole Proprietor?:No
Enumeration Date:2017-09-20
Last Update Date:2023-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ6905207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ14099384OtherCAQH
AZ6905OtherPHYSICIAN ASSISTANT AZ STATE LICENSE