Healthcare Provider Details

I. General information

NPI: 1982854980
Provider Name (Legal Business Name): PATRICK E BALLARD DO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/25/2008
Last Update Date: 12/26/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1800 CRAIG-KLAWOCK RD
CRAIG AK
99921-0000
US

IV. Provider business mailing address

PO BOX 805
CRAIG AK
99921-0805
US

V. Phone/Fax

Practice location:
  • Phone: 907-826-3257
  • Fax:
Mailing address:
  • Phone: 907-826-3257
  • Fax: 907-826-3259

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number4962
License Number StateAK
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number7047
License Number StateAK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: