Provider Demographics
NPI:1720485147
Name:BALLOU, ELISE W (PA-C)
Entity type:Individual
Prefix:
First Name:ELISE
Middle Name:W
Last Name:BALLOU
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:275 E RIVULON BLVD STE 201
Mailing Address - Street 2:
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85297-0008
Mailing Address - Country:US
Mailing Address - Phone:602-734-5664
Mailing Address - Fax:480-401-3844
Practice Address - Street 1:275 E RIVULON BLVD STE 201
Practice Address - Street 2:
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85297-0008
Practice Address - Country:US
Practice Address - Phone:602-734-5664
Practice Address - Fax:480-401-3844
Is Sole Proprietor?:No
Enumeration Date:2014-12-01
Last Update Date:2018-04-10
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
AZ5902363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical