Provider Demographics
NPI:1841563442
Name:BALLARD, MARK MCALLISTER (CRNA)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:MCALLISTER
Last Name:BALLARD
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:903 WILLOWBANK RD
Mailing Address - Street 2:
Mailing Address - City:GEORGETOWN
Mailing Address - State:SC
Mailing Address - Zip Code:29440-3363
Mailing Address - Country:US
Mailing Address - Phone:843-485-4734
Mailing Address - Fax:
Practice Address - Street 1:130 PRESERVATION CIR
Practice Address - Street 2:
Practice Address - City:PAWLEYS ISLAND
Practice Address - State:SC
Practice Address - Zip Code:29585-8219
Practice Address - Country:US
Practice Address - Phone:843-240-8047
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-14
Last Update Date:2012-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC17742367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered