Healthcare Provider Details

I. General information

NPI: 1316371586
Provider Name (Legal Business Name): RYAN DAN BINGHAM FPMHNP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/23/2013
Last Update Date: 04/23/2021
Certification Date: 04/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 COLE AVE
BISBEE AZ
85603-1327
US

IV. Provider business mailing address

3644 W HIGHWAY 80
BISBEE AZ
85603-6012
US

V. Phone/Fax

Practice location:
  • Phone: 520-432-2042
  • Fax: 520-432-2098
Mailing address:
  • Phone: 801-885-4765
  • Fax: 520-432-2098

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberAP5161
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: