Provider Demographics
NPI:1356310825
Name:KING, ALEXIS D (CRNA)
Entity Type:Individual
Prefix:
First Name:ALEXIS
Middle Name:D
Last Name:KING
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:585 S DEER TRAK
Mailing Address - Street 2:
Mailing Address - City:GARDEN CITY
Mailing Address - State:KS
Mailing Address - Zip Code:67846-8995
Mailing Address - Country:US
Mailing Address - Phone:620-290-2466
Mailing Address - Fax:620-272-2489
Practice Address - Street 1:585 S DEER TRAK
Practice Address - Street 2:
Practice Address - City:GARDEN CITY
Practice Address - State:KS
Practice Address - Zip Code:67846-8995
Practice Address - Country:US
Practice Address - Phone:620-290-2466
Practice Address - Fax:620-272-2489
Is Sole Proprietor?:No
Enumeration Date:2006-03-16
Last Update Date:2009-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS55377163W00000X, 367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS200258970BMedicaid
NC2618944Medicare PIN
KS145066Medicare ID - Type Unspecified