Provider Demographics
NPI:1871142893
Name:BINGHAM, MARSHALL DOUGLAS (PTA)
Entity type:Individual
Prefix:
First Name:MARSHALL
Middle Name:DOUGLAS
Last Name:BINGHAM
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1534 E RAY RD STE 104
Mailing Address - Street 2:
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85296-4429
Mailing Address - Country:US
Mailing Address - Phone:480-855-5542
Mailing Address - Fax:480-855-5756
Practice Address - Street 1:1534 E RAY RD STE 104
Practice Address - Street 2:
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85296-4429
Practice Address - Country:US
Practice Address - Phone:480-855-5542
Practice Address - Fax:480-855-5756
Is Sole Proprietor?:No
Enumeration Date:2019-09-11
Last Update Date:2019-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ13957225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ13957OtherPTA STATE LLICENCE