Provider Demographics
NPI:1508200452
Name:BALOUGH, DENNIS TERRANCE (PA-C)
Entity Type:Individual
Prefix:
First Name:DENNIS
Middle Name:TERRANCE
Last Name:BALOUGH
Suffix:
Gender:M
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 1:6403 COYLE AVE STE 170
Mailing Address - Street 2:
Mailing Address - City:CARMICHAEL
Mailing Address - State:CA
Mailing Address - Zip Code:95608-0363
Mailing Address - Country:US
Mailing Address - Phone:916-965-4000
Mailing Address - Fax:916-965-4813
Practice Address - Street 1:6403 COYLE AVE STE 170
Practice Address - Street 2:
Practice Address - City:CARMICHAEL
Practice Address - State:CA
Practice Address - Zip Code:95608-0363
Practice Address - Country:US
Practice Address - Phone:916-965-4000
Practice Address - Fax:916-965-4813
Is Sole Proprietor?:No
Enumeration Date:2013-04-22
Last Update Date:2022-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA22836363A00000X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACA120934Medicare PIN