Provider Demographics
NPI:1164636304
Name:KING, MARISA LEIGH (PAC)
Entity Type:Individual
Prefix:
First Name:MARISA
Middle Name:LEIGH
Last Name:KING
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:MARISA
Other - Middle Name:LEIGH
Other - Last Name:STROTHER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5000 COX RD
Mailing Address - Street 2:
Mailing Address - City:GLEN ALLEN
Mailing Address - State:VA
Mailing Address - Zip Code:23060-9263
Mailing Address - Country:US
Mailing Address - Phone:804-968-5700
Mailing Address - Fax:
Practice Address - Street 1:3432 HOLLAND RD
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23452-4846
Practice Address - Country:US
Practice Address - Phone:757-468-1855
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-09
Last Update Date:2019-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110006161363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant