Provider Demographics
NPI:1790802775
Name:BALLARD, RONALD (PA)
Entity Type:Individual
Prefix:
First Name:RONALD
Middle Name:
Last Name:BALLARD
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5080 SPECTRUM DR
Mailing Address - Street 2:SUITE 1200 WEST
Mailing Address - City:ADDISON
Mailing Address - State:TX
Mailing Address - Zip Code:75001-4648
Mailing Address - Country:US
Mailing Address - Phone:972-364-8084
Mailing Address - Fax:
Practice Address - Street 1:2151 E JEFFERSON AVE
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48207-4161
Practice Address - Country:US
Practice Address - Phone:615-778-4066
Practice Address - Fax:615-778-9114
Is Sole Proprietor?:No
Enumeration Date:2007-03-23
Last Update Date:2009-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601002277363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIMI1503Medicare PIN
MIMI1504Medicare PIN
MIMI1503039Medicare UPIN
MIMI1504039Medicare UPIN