Healthcare Provider Details

I. General information

NPI: 1124760277
Provider Name (Legal Business Name): COLBY BALLARD PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/10/2022
Last Update Date: 04/13/2026
Certification Date: 04/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5000 CENTRE GREEN WAY
CARY NC
27513-5817
US

IV. Provider business mailing address

1615 POLO RD
WINSTON SALEM NC
27106-3831
US

V. Phone/Fax

Practice location:
  • Phone: 702-703-5597
  • Fax:
Mailing address:
  • Phone: 336-722-7266
  • Fax: 336-201-0538

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0010-12502
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: