Provider Demographics
NPI:1356747323
Name:BALLABAN, ABIGAIL (AC169718)
Entity type:Individual
Prefix:
First Name:ABIGAIL
Middle Name:
Last Name:BALLABAN
Suffix:
Gender:F
Credentials:AC169718
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15524 NE HALSEY ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97230-5337
Mailing Address - Country:US
Mailing Address - Phone:503-389-8938
Mailing Address - Fax:
Practice Address - Street 1:12555 SW 1ST ST.
Practice Address - Street 2:SAGE CENTER
Practice Address - City:BEAVERTON
Practice Address - State:OR
Practice Address - Zip Code:97005
Practice Address - Country:US
Practice Address - Phone:503-389-8938
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-18
Last Update Date:2016-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORAC169718171100000X
WAAC 60504025171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist