Provider Demographics
NPI:1316427651
Name:BALLIET, JUSTIN KYLE (PA-C)
Entity type:Individual
Prefix:
First Name:JUSTIN
Middle Name:KYLE
Last Name:BALLIET
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:340 MEDIA STATION RD APT C311
Mailing Address - Street 2:
Mailing Address - City:MEDIA
Mailing Address - State:PA
Mailing Address - Zip Code:19063-4787
Mailing Address - Country:US
Mailing Address - Phone:570-778-1933
Mailing Address - Fax:
Practice Address - Street 1:1 BARTOL AVE STE 14
Practice Address - Street 2:
Practice Address - City:RIDLEY PARK
Practice Address - State:PA
Practice Address - Zip Code:19078-2214
Practice Address - Country:US
Practice Address - Phone:610-521-9074
Practice Address - Fax:610-521-9074
Is Sole Proprietor?:No
Enumeration Date:2018-08-16
Last Update Date:2018-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOA004604363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0015234460006Medicaid
PA668795OtherMEDICARE UPIN