Healthcare Provider Details

I. General information

NPI: 1841337631
Provider Name (Legal Business Name): AUDRA SUZANNE BALL PAC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/31/2007
Last Update Date: 02/12/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4805 E HIGHWAY 37
TUTTLE OK
73089-8791
US

IV. Provider business mailing address

4805 E HIGHWAY 37
TUTTLE OK
73089-8791
US

V. Phone/Fax

Practice location:
  • Phone: 405-381-9979
  • Fax: 405-381-9130
Mailing address:
  • Phone: 405-381-9979
  • Fax: 405-381-9130

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number StateOK

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier200110730A
Identifier TypeMEDICAID
Identifier StateOK
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: