Provider Demographics
NPI:1265790117
Name:BALL, KRISTEN NICHOLE (PA-C)
Entity type:Individual
Prefix:MRS
First Name:KRISTEN
Middle Name:NICHOLE
Last Name:BALL
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2488 E 81ST ST STE 290
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74137-4265
Mailing Address - Country:US
Mailing Address - Phone:918-494-2665
Mailing Address - Fax:918-927-3193
Practice Address - Street 1:2488 E 81ST ST STE 290
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74137-4265
Practice Address - Country:US
Practice Address - Phone:918-494-2665
Practice Address - Fax:918-927-3193
Is Sole Proprietor?:No
Enumeration Date:2012-04-29
Last Update Date:2022-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9106501363A00000X, 363AM0700X
OK3204363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL020432200Medicaid
OK200931390AMedicaid