Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 208000000X | Pediatrician | 36477 | AZ |
N | 208000000X | Pediatrician | A85893 | CA |
Y | 2080P0208X | Pediatric Infectious Diseases | 36477 | AZ |
N | 2080P0208X | Pediatric Infectious Diseases | A85893 | CA |
NPI | 1598981698 |
---|---|
Provider Name | Dr. Wassim Ballan |
First Address | Chandler, AZ 85246-8022 |
Second Address | Phoenix, AZ 85016-7710 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 17/04/2007 |
Last Update Date | 31/07/2019 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
230583-01 | (05) | AZ |
36477 | AZ MEDICAL LICENSE (01) | AZ |
A85893 | CA MEDICAL LICENSE (01) | CA |