Provider Demographics
NPI:1528178563
Name:KING, NATHALIE ANNE (PA)
Entity Type:Individual
Prefix:MRS
First Name:NATHALIE
Middle Name:ANNE
Last Name:KING
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:MATHALIE
Other - Middle Name:ANNE
Other - Last Name:GALLO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:3805B SPRING ST
Mailing Address - Street 2:SUITE 320
Mailing Address - City:RACINE
Mailing Address - State:WI
Mailing Address - Zip Code:53405-1641
Mailing Address - Country:US
Mailing Address - Phone:262-687-8322
Mailing Address - Fax:
Practice Address - Street 1:3805B SPRING ST
Practice Address - Street 2:SUITE 320
Practice Address - City:RACINE
Practice Address - State:WI
Practice Address - Zip Code:53405-1641
Practice Address - Country:US
Practice Address - Phone:262-687-8322
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2011-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1807363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39-1264986OtherTAX ID