Basic Information
| Provider Information | |||||||||
| NPI: | 1841475126 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BALL | ||||||||
| FirstName: | GENIE | ||||||||
| MiddleName: | NOELLE | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PA-C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | KOUTROUPAS | ||||||||
| OtherFirstName: | GENIE | ||||||||
| OtherMiddleName: | NOELLE | ||||||||
| OtherNamePrefix: | MS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | PA-C | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 32 STRAWBERRY HILL CT | ||||||||
| Address2: | SUITE 11001 | ||||||||
| City: | STAMFORD | ||||||||
| State: | CT | ||||||||
| PostalCode: | 069022594 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2032764400 | ||||||||
| FaxNumber: | 2032764401 | ||||||||
| Practice Location | |||||||||
| Address1: | 32 STRAWBERRY HILL CT | ||||||||
| Address2: | SUITE 11001 | ||||||||
| City: | STAMFORD | ||||||||
| State: | CT | ||||||||
| PostalCode: | 069022594 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2032764400 | ||||||||
| FaxNumber: | 2032764401 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/04/2008 | ||||||||
| LastUpdateDate: | 09/20/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AS0400X | 2003 | CT | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical |
ID Information
| ID | Type | State | Issuer | Description | 003020039 | 05 | CT | MEDICAID |