Provider Demographics
NPI:1518130244
Name:KING, AUTUMN AMBROSE (PT)
Entity Type:Individual
Prefix:
First Name:AUTUMN
Middle Name:AMBROSE
Last Name:KING
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:246 SOBRANTE WAY
Mailing Address - Street 2:
Mailing Address - City:SUNNYVALE
Mailing Address - State:CA
Mailing Address - Zip Code:94086-4807
Mailing Address - Country:US
Mailing Address - Phone:408-733-3670
Mailing Address - Fax:408-245-7968
Practice Address - Street 1:670 E CALAVERAS BLVD
Practice Address - Street 2:
Practice Address - City:MILPITAS
Practice Address - State:CA
Practice Address - Zip Code:95035-5442
Practice Address - Country:US
Practice Address - Phone:408-934-4700
Practice Address - Fax:408-934-4701
Is Sole Proprietor?:No
Enumeration Date:2008-04-02
Last Update Date:2009-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT 34574225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACF024ZMedicare PIN
CA0PT345740Medicare PIN