Provider Demographics
NPI:1487026191
Name:BALLS, JESSE J (PA-C)
Entity Type:Individual
Prefix:
First Name:JESSE
Middle Name:J
Last Name:BALLS
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:794 EASTLAND DR
Mailing Address - Street 2:
Mailing Address - City:TWIN FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83301-6856
Mailing Address - Country:US
Mailing Address - Phone:208-737-6718
Mailing Address - Fax:
Practice Address - Street 1:218 W NEZ PERCE
Practice Address - Street 2:
Practice Address - City:JEROME
Practice Address - State:ID
Practice Address - Zip Code:83338-5193
Practice Address - Country:US
Practice Address - Phone:208-324-3471
Practice Address - Fax:208-324-9191
Is Sole Proprietor?:No
Enumeration Date:2015-10-21
Last Update Date:2021-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPA-1439363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1374812Medicare Oscar/Certification