Provider Demographics
NPI:1720022395
Name:BALLARD, GARY H (NP)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:H
Last Name:BALLARD
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:992 CLIFT CAVE RD
Mailing Address - Street 2:
Mailing Address - City:SODDY DAISY
Mailing Address - State:TN
Mailing Address - Zip Code:37379-5700
Mailing Address - Country:US
Mailing Address - Phone:423-332-9218
Mailing Address - Fax:423-605-4704
Practice Address - Street 1:403 MCBRIEN RD
Practice Address - Street 2:
Practice Address - City:EAST RIDGE
Practice Address - State:TN
Practice Address - Zip Code:37412-3223
Practice Address - Country:US
Practice Address - Phone:423-894-3589
Practice Address - Fax:423-892-3378
Is Sole Proprietor?:No
Enumeration Date:2006-06-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNRN0000063398363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
3904231Medicare ID - Type Unspecified
P39094Medicare UPIN