Healthcare Provider Details

I. General information

NPI: 1740241553
Provider Name (Legal Business Name): LA DENA ANN BALLARD PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/31/2006
Last Update Date: 11/12/2024
Certification Date: 11/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2431 E 61ST ST STE 500
TULSA OK
74136-1208
US

IV. Provider business mailing address

2431 E 61ST ST STE 500
TULSA OK
74136-1208
US

V. Phone/Fax

Practice location:
  • Phone: 918-582-6800
  • Fax: 918-582-6060
Mailing address:
  • Phone: 918-582-6800
  • Fax: 918-582-6060

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number1467
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: