MEDICARE: STEPHANIE TRENT BALLARD PHYSICIAN ASSISTANT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	0010-04664	NC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1083037691
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	STEPHANIE TRENT BALLARD PHYSICIAN ASSISTANT

Provider Business Mailing Address
First Line	:	2587 HENDERSON DR
Second Line	:
City	:	JACKSONVILLE
State	:	NC
Zip	:	28546-5253
Country	:	US
Telephone Number	:	910-938-3200
Fax Number	:

Provider Business Practice Location Address
First Line	:	2587 HENDERSON DR
Second Line	:
City	:	JACKSONVILLE
State	:	NC
Zip	:	28546-5253
Country	:	US
Telephone Number	:	910-938-3200
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/03/2014
Last Update Date	:	06/15/2020

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