Provider Demographics
NPI:1245250414
Name:BALL, ROGER LEON
Entity type:Individual
Prefix:
First Name:ROGER
Middle Name:LEON
Last Name:BALL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:ROGER
Other - Middle Name:L
Other - Last Name:BALL
Other - Suffix:II
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:225 176TH ST S
Mailing Address - Street 2:
Mailing Address - City:SPANAWAY
Mailing Address - State:WA
Mailing Address - Zip Code:98387-9201
Mailing Address - Country:US
Mailing Address - Phone:253-459-7770
Mailing Address - Fax:
Practice Address - Street 1:225 176TH ST S
Practice Address - Street 2:
Practice Address - City:SPANAWAY
Practice Address - State:WA
Practice Address - Zip Code:98387-9201
Practice Address - Country:US
Practice Address - Phone:253-459-7770
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-20
Last Update Date:2016-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
WAPA60581899363A00000X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
KYVAD000Medicare UPIN