Provider Demographics
NPI:1063947901
Name:BALLARD, ANGELA NEVA (PA-C)
Entity type:Individual
Prefix:
First Name:ANGELA
Middle Name:NEVA
Last Name:BALLARD
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:ANGELA
Other - Middle Name:NEVA
Other - Last Name:CORREALE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:6034 W COURTYARD DR STE 110
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78730-5064
Mailing Address - Country:US
Mailing Address - Phone:512-328-2266
Mailing Address - Fax:
Practice Address - Street 1:4201 BEE CAVES RD STE C100
Practice Address - Street 2:
Practice Address - City:WEST LAKE HILLS
Practice Address - State:TX
Practice Address - Zip Code:78746-6493
Practice Address - Country:US
Practice Address - Phone:512-327-1155
Practice Address - Fax:512-327-1156
Is Sole Proprietor?:No
Enumeration Date:2017-04-28
Last Update Date:2023-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA11153363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX370638401Medicaid