Provider Demographics
NPI:1700825981
Name:BALLARD, KEVIN D (NP)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:D
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 1:323 S MINNESOTA ST
Mailing Address - Street 2:
Mailing Address - City:CROOKSTON
Mailing Address - State:MN
Mailing Address - Zip Code:56716-1601
Mailing Address - Country:US
Mailing Address - Phone:218-253-4606
Mailing Address - Fax:
Practice Address - Street 1:323 S MINNESOTA ST
Practice Address - Street 2:
Practice Address - City:CROOKSTON
Practice Address - State:MN
Practice Address - Zip Code:56716-1601
Practice Address - Country:US
Practice Address - Phone:218-253-4606
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-05
Last Update Date:2009-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR28679363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND19961Medicaid
MN23441OtherND BC
MN726183700Medicaid
MN142320OtherUCARE #
ND19666OtherND MA
MN365Y6BAOtherBC MN
MN726183700Medicaid
MN142320OtherUCARE #
MN500002524Medicare PIN