Provider Demographics
NPI:1972567451
Name:BALL, RANDALL (PA-C)
Entity type:Individual
Prefix:
First Name:RANDALL
Middle Name:
Last Name:BALL
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 1:2412 RING RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:ELIZABETHTOWN
Mailing Address - State:KY
Mailing Address - Zip Code:42701-5912
Mailing Address - Country:US
Mailing Address - Phone:270-737-2273
Mailing Address - Fax:270-735-9087
Practice Address - Street 1:245 FOUNTAIN CT FL 1
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40509-2792
Practice Address - Country:US
Practice Address - Phone:859-218-2626
Practice Address - Fax:859-257-3322
Is Sole Proprietor?:No
Enumeration Date:2006-04-13
Last Update Date:2023-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYPA241363AM0700X, 363AS0400X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
S70528Medicare UPIN
KY0715627Medicare ID - Type Unspecified