Provider Demographics
NPI:1437272820
Name:KING, CONSTANCE (PHYSICIAN ASSISTANT)
Entity Type:Individual
Prefix:MRS
First Name:CONSTANCE
Middle Name:
Last Name:KING
Suffix:
Gender:F
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6546 S 1580 E
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84121-2517
Mailing Address - Country:US
Mailing Address - Phone:801-272-0604
Mailing Address - Fax:
Practice Address - Street 1:1225 FORT UNION BLVD
Practice Address - Street 2:200
Practice Address - City:MIDVALE
Practice Address - State:UT
Practice Address - Zip Code:84047-1889
Practice Address - Country:US
Practice Address - Phone:801-466-3102
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT104569-1209363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical