Provider Demographics
NPI:1891794657
Name:BALLOU, LEIGH ANN (PA-C)
Entity Type:Individual
Prefix:
First Name:LEIGH
Middle Name:ANN
Last Name:BALLOU
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25455 BARTON RD
Mailing Address - Street 2:SUITE 108-A
Mailing Address - City:LOMA LINDA
Mailing Address - State:CA
Mailing Address - Zip Code:92354-3128
Mailing Address - Country:US
Mailing Address - Phone:909-558-6386
Mailing Address - Fax:909-558-6206
Practice Address - Street 1:11234 ANDERSON ST
Practice Address - Street 2:RM 2562B
Practice Address - City:LOMA LINDA
Practice Address - State:CA
Practice Address - Zip Code:92354-2804
Practice Address - Country:US
Practice Address - Phone:909-558-6386
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA16765363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical