Provider Demographics
NPI:1891297776
Name:BALL, BLAIR ANDREW
Entity Type:Individual
Prefix:
First Name:BLAIR
Middle Name:ANDREW
Last Name:BALL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1533 E WILLETTA ST
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85006-2935
Mailing Address - Country:US
Mailing Address - Phone:602-569-3999
Mailing Address - Fax:602-569-3887
Practice Address - Street 1:15235 N DYSART RD
Practice Address - Street 2:
Practice Address - City:EL MIRAGE
Practice Address - State:AZ
Practice Address - Zip Code:85335-9738
Practice Address - Country:US
Practice Address - Phone:602-569-3999
Practice Address - Fax:602-569-3887
Is Sole Proprietor?:No
Enumeration Date:2018-03-06
Last Update Date:2020-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID57937207Q00000X
AZAP11340363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ421665Medicaid