Provider Demographics
NPI:1376564799
Name:BALLARD, BRET (NP)
Entity Type:Individual
Prefix:
First Name:BRET
Middle Name:
Last Name:BALLARD
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:906 HIGHWAY 278 E
Mailing Address - Street 2:
Mailing Address - City:AMORY
Mailing Address - State:MS
Mailing Address - Zip Code:38821-5511
Mailing Address - Country:US
Mailing Address - Phone:662-256-5612
Mailing Address - Fax:662-256-5264
Practice Address - Street 1:906 HIGHWAY 278 E
Practice Address - Street 2:
Practice Address - City:AMORY
Practice Address - State:MS
Practice Address - Zip Code:38821-5511
Practice Address - Country:US
Practice Address - Phone:662-256-5612
Practice Address - Fax:662-256-5264
Is Sole Proprietor?:No
Enumeration Date:2006-07-21
Last Update Date:2019-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR815978363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MEP74600Medicare UPIN