Provider Demographics
NPI:1154324945
Name:KING, STANLEY THOMAS (PA)
Entity Type:Individual
Prefix:
First Name:STANLEY
Middle Name:THOMAS
Last Name:KING
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:205 HOSPITAL DR
Mailing Address - Street 2:STE A
Mailing Address - City:MC KENZIE
Mailing Address - State:TN
Mailing Address - Zip Code:38201-1649
Mailing Address - Country:US
Mailing Address - Phone:731-352-7907
Mailing Address - Fax:731-352-4459
Practice Address - Street 1:205 HOSPITAL DR
Practice Address - Street 2:STE A
Practice Address - City:MC KENZIE
Practice Address - State:TN
Practice Address - Zip Code:38201-1649
Practice Address - Country:US
Practice Address - Phone:731-352-7907
Practice Address - Fax:731-352-4459
Is Sole Proprietor?:No
Enumeration Date:2005-05-24
Last Update Date:2013-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNPA88363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1510135Medicaid
TNPA88OtherPHYSICIAN ASSISTANT LICEN
TNPA88OtherPHYSICIAN ASSISTANT LICEN
TNR70531Medicare UPIN