Provider Demographics
NPI:1225737463
Name:KING, MIRIAM JEAN (PTA)
Entity Type:Individual
Prefix:
First Name:MIRIAM
Middle Name:JEAN
Last Name:KING
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11001 BREN RD E UNIT 424
Mailing Address - Street 2:
Mailing Address - City:MINNETONKA
Mailing Address - State:MN
Mailing Address - Zip Code:55343-4442
Mailing Address - Country:US
Mailing Address - Phone:952-237-2362
Mailing Address - Fax:
Practice Address - Street 1:7505 COUNTRY CLUB DR
Practice Address - Street 2:
Practice Address - City:GOLDEN VALLEY
Practice Address - State:MN
Practice Address - Zip Code:55427-4501
Practice Address - Country:US
Practice Address - Phone:763-450-6900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-27
Last Update Date:2023-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNA1123225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant