Provider Demographics
NPI:1578072245
Name:BAL, GAGANDEEP
Entity Type:Individual
Prefix:
First Name:GAGANDEEP
Middle Name:
Last Name:BAL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:TINA
Other - Middle Name:
Other - Last Name:BAL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:NP-C
Mailing Address - Street 1:11 PROFESSIONAL PKWY
Mailing Address - Street 2:
Mailing Address - City:RIDGELAND
Mailing Address - State:MS
Mailing Address - Zip Code:39157-4114
Mailing Address - Country:US
Mailing Address - Phone:601-856-2460
Mailing Address - Fax:601-856-4687
Practice Address - Street 1:11 PROFESSIONAL PKWY
Practice Address - Street 2:
Practice Address - City:RIDGELAND
Practice Address - State:MS
Practice Address - Zip Code:39157-4114
Practice Address - Country:US
Practice Address - Phone:601-856-2460
Practice Address - Fax:601-856-4687
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-26
Last Update Date:2017-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS901853363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MSF0716953OtherMEDICAL LICENSE