Provider Demographics
NPI:1215011820
Name:BALLARD, MARGUERITE MAUTNER (PA-C)
Entity Type:Individual
Prefix:
First Name:MARGUERITE
Middle Name:MAUTNER
Last Name:BALLARD
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 1:2050 PROGRESS WAY
Mailing Address - Street 2:
Mailing Address - City:WOODBURN
Mailing Address - State:OR
Mailing Address - Zip Code:97071-9764
Mailing Address - Country:US
Mailing Address - Phone:503-981-5348
Mailing Address - Fax:503-981-1236
Practice Address - Street 1:2050 PROGRESS WAY
Practice Address - Street 2:
Practice Address - City:WOODBURN
Practice Address - State:OR
Practice Address - Zip Code:97071-9764
Practice Address - Country:US
Practice Address - Phone:503-981-5348
Practice Address - Fax:503-981-1236
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-24
Last Update Date:2015-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPA00267363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical