Provider Demographics
NPI:1841337631
Name:BALL, AUDRA SUZANNE (PAC)
Entity type:Individual
Prefix:MS
First Name:AUDRA
Middle Name:SUZANNE
Last Name:BALL
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4805 E HIGHWAY 37
Mailing Address - Street 2:
Mailing Address - City:TUTTLE
Mailing Address - State:OK
Mailing Address - Zip Code:73089-8791
Mailing Address - Country:US
Mailing Address - Phone:405-381-9979
Mailing Address - Fax:405-381-9130
Practice Address - Street 1:4805 E HIGHWAY 37
Practice Address - Street 2:
Practice Address - City:TUTTLE
Practice Address - State:OK
Practice Address - Zip Code:73089-8791
Practice Address - Country:US
Practice Address - Phone:405-381-9979
Practice Address - Fax:405-381-9130
Is Sole Proprietor?:No
Enumeration Date:2007-01-31
Last Update Date:2009-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200110730AMedicaid
OK242708905Medicare PIN