| Doctor Name: | CORBIN BALLAM |
| NPI Number: | 1205282894 |
| Entity Type Code: | Individual (1) |
| Gender: | M |
| Credentials: | |
| License Number: | |
| Business Practice Address: | 5700 Az-90 Sierra Vista, AZ - 85635 |
| Business Phone Number: | 5202632000 |
| Business Fax Number: | |
| Mailing Address: | 1320 N 200 E, Apt 316 LOGAN |
| State: | UT |
| Postal Code: | 843412452 |
| Phone Number: | 4355312865 |
| Fax Number: | |
| NPI Enumeration Date: | 05/12/2016 |
| NPI Last Update Date: | 05/12/2016 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 390200000X |
| License Number: | |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | |
| Taxonomy Type: | Student, Health Care |
| Taxonomy Classification: | Student in an Organized Health Care Education/Training Program |
| Taxonomy Specialization: | |
| Taxonomy Definition: | An individual who is enrolled in an organized health care education/training program leading to a degree, certification, registration, and/or licensure to provide health care. |