Provider Demographics
NPI:1205826245
Name:KING, RACHEL (PA)
Entity Type:Individual
Prefix:
First Name:RACHEL
Middle Name:
Last Name:KING
Suffix:
Gender:F
Credentials:PA
Other - Prefix:MRS
Other - First Name:RACHEL
Other - Middle Name:
Other - Last Name:KING
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PA
Mailing Address - Street 1:6454 W EMERALD ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83704-8734
Mailing Address - Country:US
Mailing Address - Phone:208-377-0820
Mailing Address - Fax:208-375-8046
Practice Address - Street 1:6454 W EMERALD ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-8734
Practice Address - Country:US
Practice Address - Phone:208-377-0820
Practice Address - Fax:208-375-8046
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-21
Last Update Date:2021-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPA521363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID000010148622OtherBLUE SHIELD
IDPACD0OtherBLUE CROSS
IDPAMR8OtherBLUE CROSS
ID807029900Medicaid
ID000010148623OtherBLUE SHIELD
ID807029900Medicaid
IDP00206260Medicare ID - Type UnspecifiedRAILROAD
ID000010148622OtherBLUE SHIELD