MEDICARE: MR. PAUL ALLEN BALLARD PA-C, ATC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	307181	LA
2	363AS0400X	Surgical Physician Assistant		LA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	14219851	OTHER		CAQH

General Provider Information

NPI Number	:	1114445798
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. PAUL ALLEN BALLARD PA-C, ATC

Provider Business Mailing Address
First Line	:	1455 E BERT KOUNS INDUSTRIAL LOOP
Second Line	:
City	:	SHREVEPORT
State	:	LA
Zip	:	71105-6000
Country	:	US
Telephone Number	:	318-798-4500
Fax Number	:	318-798-4601

Provider Business Practice Location Address
First Line	:	5025 SHED RD
Second Line	:
City	:	BOSSIER CITY
State	:	LA
Zip	:	71111-5434
Country	:	US
Telephone Number	:	318-798-4623
Fax Number	:	318-795-4742

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/05/2017
Last Update Date	:	02/02/2026

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