Provider Demographics
NPI:1457858417
Name:KING, KISA S (MD)
Entity Type:Individual
Prefix:DR
First Name:KISA
Middle Name:S
Last Name:KING
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2211 LOMAS BLVD NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87106-2719
Mailing Address - Country:US
Mailing Address - Phone:575-571-5100
Mailing Address - Fax:
Practice Address - Street 1:2211 LOMAS BLVD NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87106-2719
Practice Address - Country:US
Practice Address - Phone:575-571-5100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-06
Last Update Date:2023-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY310031207P00000X
390200000X
NMNM2022-0838207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program