Provider Demographics
NPI:1427873561
Name:BALTAZAR, ASHTON RILEY
Entity type:Individual
Prefix:
First Name:ASHTON
Middle Name:RILEY
Last Name:BALTAZAR
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2820 E 1ST ST
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74104-1702
Mailing Address - Country:US
Mailing Address - Phone:817-688-5534
Mailing Address - Fax:
Practice Address - Street 1:4502 EAST 41ST ST.
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74135
Practice Address - Country:US
Practice Address - Phone:918-660-3842
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-11-21
Last Update Date:2024-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program