Provider Demographics
NPI:1114445798
Name:BALLARD, PAUL ALLEN (PA-C, ATC)
Entity Type:Individual
Prefix:MR
First Name:PAUL
Middle Name:ALLEN
Last Name:BALLARD
Suffix:
Gender:M
Credentials:PA-C, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1455 E BERT KOUNS INDUSTRIAL LOOP STE 210
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71105-6000
Mailing Address - Country:US
Mailing Address - Phone:318-798-4623
Mailing Address - Fax:
Practice Address - Street 1:1455 E BERT KOUNS INDUSTRIAL LOOP STE 210
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71105-6000
Practice Address - Country:US
Practice Address - Phone:318-798-4623
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-05
Last Update Date:2023-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA363AS0400X
LA307181363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical