Provider Demographics
NPI:1336483015
Name:KING, MOLLY M (PA-C)
Entity Type:Individual
Prefix:
First Name:MOLLY
Middle Name:M
Last Name:KING
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2316 INDIAN SPRINGS DR
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32246-4184
Mailing Address - Country:US
Mailing Address - Phone:919-302-9524
Mailing Address - Fax:
Practice Address - Street 1:6555 CHESTER AVE STE 1
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32217-2279
Practice Address - Country:US
Practice Address - Phone:904-265-8209
Practice Address - Fax:904-503-3577
Is Sole Proprietor?:No
Enumeration Date:2012-11-19
Last Update Date:2020-08-28
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLPA9106964363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL010438100Medicaid
FLPA9106964OtherMEDICAL LICENSE
FL010438100Medicaid