Provider Demographics
NPI:1114387123
Name:FORD, BALEIGH (PA-C)
Entity Type:Individual
Prefix:
First Name:BALEIGH
Middle Name:
Last Name:FORD
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:499 SPRINGRIDGE RD
Mailing Address - Street 2:LOT B1
Mailing Address - City:CLINTON
Mailing Address - State:MS
Mailing Address - Zip Code:39056-5600
Mailing Address - Country:US
Mailing Address - Phone:601-319-0685
Mailing Address - Fax:
Practice Address - Street 1:2080 S FRONTAGE RD
Practice Address - Street 2:#100
Practice Address - City:VICKSBURG
Practice Address - State:MS
Practice Address - Zip Code:39180-5328
Practice Address - Country:US
Practice Address - Phone:601-262-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-03-03
Last Update Date:2016-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPA00275363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical