Provider Demographics
NPI:1093286015
Name:KING, SHADARA (AGNP-C)
Entity Type:Individual
Prefix:MRS
First Name:SHADARA
Middle Name:
Last Name:KING
Suffix:
Gender:F
Credentials:AGNP-C
Other - Prefix:
Other - First Name:SHADARA
Other - Middle Name:
Other - Last Name:EDMOND
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:185 TIMBER WOLF XING
Mailing Address - Street 2:
Mailing Address - City:GARNER
Mailing Address - State:NC
Mailing Address - Zip Code:27529-9279
Mailing Address - Country:US
Mailing Address - Phone:302-228-6434
Mailing Address - Fax:910-348-7961
Practice Address - Street 1:3214 CHARLES B ROOT WYND STE 203
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27612-5440
Practice Address - Country:US
Practice Address - Phone:919-877-6800
Practice Address - Fax:844-881-7701
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-17
Last Update Date:2023-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DELP-0010645363L00000X
TN33592363L00000X
SC27576363L00000X
AL3-001270363L00000X
NC5011293363LA2200X, 363L00000X
GAAG03180040363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health