Provider Demographics
NPI:1013090216
Name:BALKO, JILLANN M (CRNA)
Entity Type:Individual
Prefix:
First Name:JILLANN
Middle Name:M
Last Name:BALKO
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1370 JOHNSON AVE STE 102
Mailing Address - Street 2:
Mailing Address - City:BRIDGEPORT
Mailing Address - State:WV
Mailing Address - Zip Code:26330-1492
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1 MEDICAL CENTER DR
Practice Address - Street 2:
Practice Address - City:MORGANTOWN
Practice Address - State:WV
Practice Address - Zip Code:26506-1200
Practice Address - Country:US
Practice Address - Phone:304-598-4122
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-23
Last Update Date:2024-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV50514367500000X
WVAPRN50514367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV001706470OtherMSBSBS
WVDA0096OtherRR MEDICARE
WV27005299701OtherWORKERS COMP
WV270052997004OtherTRICARE
WV0207026000Medicaid
WV27005299701OtherBRICKSTREET
WVP00207323OtherRR MEDICARE
WV001720735OtherMT STATE BCBS
WV2601027000Medicaid
WV270052997004OtherTRICARE
WV9333201Medicare PIN