1154621613 NPI number — JUDITH A KING MN FNP PC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1154621613 NPI number — JUDITH A KING MN FNP PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JUDITH A KING MN FNP PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1154621613
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/14/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
124 NW MIDLAND AVE STE 107
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GRANTS PASS
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97526-1269
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
541-474-5665
Provider Business Mailing Address Fax Number:
541-474-4435

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
124 NW MIDLAND AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GRANTS PASS
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97526-1269
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-474-5665
Provider Business Practice Location Address Fax Number:
541-474-4435
Provider Enumeration Date:
10/29/2010

Additional Information

Authorized Official

Authorized Official Last Name:
KING
Authorized Official First Name:
JUDITH
Authorized Official Middle Name:
A
Authorized Official Title or Position:
OWNER/PROVIDER
Authorized Official Telephone Number:
541-474-5665

Provider Taxonomy Codes

  • Taxonomy code: 363LF0000X , with the licence number:  000037306N1 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 900109622 . This is a "MEDICARE RR" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".
  • Identifier: 108613 . This is a "MEDICARE ID-TYPE UNSPECIFIED" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".
  • Identifier: R108613 . This is a "MEDICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 074450 , issued by the state of ( OR ) . This identifiers is of the category "MEDICAID".




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