Provider Demographics
NPI:1720288756
Name:BALLARD, SALLY J (PA-C)
Entity Type:Individual
Prefix:
First Name:SALLY
Middle Name:J
Last Name:BALLARD
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 1:200 S BROADWAY
Mailing Address - Street 2:PO BOX 40
Mailing Address - City:GOREVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62939
Mailing Address - Country:US
Mailing Address - Phone:618-995-2396
Mailing Address - Fax:618-995-2947
Practice Address - Street 1:200 S BROADWAY
Practice Address - Street 2:
Practice Address - City:GOREVILLE
Practice Address - State:IL
Practice Address - Zip Code:62939
Practice Address - Country:US
Practice Address - Phone:618-995-2396
Practice Address - Fax:618-995-2947
Is Sole Proprietor?:No
Enumeration Date:2007-07-18
Last Update Date:2007-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL215389OtherMEDICARE GROUP NUMBER
ILK40932Medicare PIN