Provider Demographics
NPI:1811518541
Name:BALLARD, AUTUMN ROSE (PA-C)
Entity type:Individual
Prefix:
First Name:AUTUMN
Middle Name:ROSE
Last Name:BALLARD
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:AUTUMN
Other - Middle Name:ROSE
Other - Last Name:KEENE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1221 S BROADWAY
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40504-2701
Mailing Address - Country:US
Mailing Address - Phone:859-258-6200
Mailing Address - Fax:859-258-6203
Practice Address - Street 1:101 MEDICAL HEIGHTS DR STE A
Practice Address - Street 2:
Practice Address - City:FRANKFORT
Practice Address - State:KY
Practice Address - Zip Code:40601-4137
Practice Address - Country:US
Practice Address - Phone:502-223-5758
Practice Address - Fax:502-223-0047
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-05
Last Update Date:2023-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
KYPA2724363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program