=====================================================
General NPI Number Information
=====================================================
NPI Number | 1740241553
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LA DENA ANN BALLARD PA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/31/2006
-----------------------------------------------------
Last Update Date | 11/12/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2431 E 61ST ST STE 500
-----------------------------------------------------
City | TULSA
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 74136-1208
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 918-582-6800
-----------------------------------------------------
Fax | 918-582-6060
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2431 E 61ST ST STE 500
-----------------------------------------------------
City | TULSA
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 74136-1208
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 918-582-6800
-----------------------------------------------------
Fax | 918-582-6060
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number | 1467
-----------------------------------------------------
License Number State | OK
-----------------------------------------------------