Provider Demographics
NPI:1316427651
Name:BALLIET, JUSTIN KYLE (PA-C)
Entity type:Individual
Prefix:
First Name:JUSTIN
Middle Name:KYLE
Last Name:BALLIET
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 1:3803 W CHESTER PIKE STE 160
Mailing Address - Street 2:
Mailing Address - City:NEWTOWN SQUARE
Mailing Address - State:PA
Mailing Address - Zip Code:19073-2336
Mailing Address - Country:US
Mailing Address - Phone:484-337-1632
Mailing Address - Fax:
Practice Address - Street 1:2000 SPROUL RD STE 100
Practice Address - Street 2:
Practice Address - City:BROOMALL
Practice Address - State:PA
Practice Address - Zip Code:19008-3509
Practice Address - Country:US
Practice Address - Phone:484-337-5314
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-16
Last Update Date:2025-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOA004604363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0015234460006Medicaid
PA668795OtherMEDICARE UPIN