Provider Demographics
NPI:1679058630
Name:BALLARD, TYLER DAVID (PA-C)
Entity Type:Individual
Prefix:
First Name:TYLER
Middle Name:DAVID
Last Name:BALLARD
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 1:2070 E HILL RD
Mailing Address - Street 2:
Mailing Address - City:GRAND BLANC
Mailing Address - State:MI
Mailing Address - Zip Code:48439-5108
Mailing Address - Country:US
Mailing Address - Phone:810-695-5353
Mailing Address - Fax:
Practice Address - Street 1:2070 E HILL RD
Practice Address - Street 2:
Practice Address - City:GRAND BLANC
Practice Address - State:MI
Practice Address - Zip Code:48439-5108
Practice Address - Country:US
Practice Address - Phone:810-695-5353
Practice Address - Fax:810-695-0616
Is Sole Proprietor?:No
Enumeration Date:2018-09-26
Last Update Date:2020-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601008839363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical