Provider Demographics
NPI:1457442691
Name:KING, MARK E (PA)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:E
Last Name:KING
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1401 SUDDERTH DR
Mailing Address - Street 2:
Mailing Address - City:RUIDOSO
Mailing Address - State:NM
Mailing Address - Zip Code:88345-6104
Mailing Address - Country:US
Mailing Address - Phone:575-257-7712
Mailing Address - Fax:575-257-4513
Practice Address - Street 1:1401 SUDDERTH DR
Practice Address - Street 2:
Practice Address - City:RUIDOSO
Practice Address - State:NM
Practice Address - Zip Code:88345-6104
Practice Address - Country:US
Practice Address - Phone:575-257-7712
Practice Address - Fax:575-257-4513
Is Sole Proprietor?:No
Enumeration Date:2006-09-27
Last Update Date:2012-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA10003262207P00000X
NM95-PA19363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA605960011OtherUSDLAB
WA3016KIOtherBSWA
WA8464794Medicaid
WA0220796OtherLIWA
WA605960011OtherUSDLAB
WAP00347913Medicare PIN
WA3016KIOtherBSWA
WAG8861983Medicare PIN