Healthcare Provider Details

I. General information

NPI: 1487026191
Provider Name (Legal Business Name): JESSE J BALLS PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/21/2015
Last Update Date: 04/08/2021
Certification Date: 03/17/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

218 W NEZ PERCE
JEROME ID
83338-5193
US

IV. Provider business mailing address

794 EASTLAND DR
TWIN FALLS ID
83301-6856
US

V. Phone/Fax

Practice location:
  • Phone: 208-324-3471
  • Fax: 208-324-9191
Mailing address:
  • Phone: 208-737-6718
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA-1439
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: