Provider Demographics
NPI:1528153558
Name:BALLARD, AMY M (PA)
Entity type:Individual
Prefix:MRS
First Name:AMY
Middle Name:M
Last Name:BALLARD
Suffix:
Gender:F
Credentials:PA
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Mailing Address - Street 1:PO BOX 7062
Mailing Address - Street 2:
Mailing Address - City:TUPELO
Mailing Address - State:MS
Mailing Address - Zip Code:38802-7062
Mailing Address - Country:US
Mailing Address - Phone:662-377-7170
Mailing Address - Fax:662-377-7180
Practice Address - Street 1:830 S GLOSTER ST
Practice Address - Street 2:NMMC EAST TOWER THIRD FLOOR
Practice Address - City:TUPELO
Practice Address - State:MS
Practice Address - Zip Code:38801-4934
Practice Address - Country:US
Practice Address - Phone:662-377-7170
Practice Address - Fax:662-377-7180
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2007-07-08
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MSPA027363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00126597Medicaid
MS00126597Medicaid