Provider Demographics
NPI:1578545497
Name:KING, KATHRINE ANN (PA)
Entity Type:Individual
Prefix:
First Name:KATHRINE
Middle Name:ANN
Last Name:KING
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2107 EATON AVE
Mailing Address - Street 2:
Mailing Address - City:BETHLEHEM
Mailing Address - State:PA
Mailing Address - Zip Code:18018-2005
Mailing Address - Country:US
Mailing Address - Phone:610-570-4172
Mailing Address - Fax:570-517-0974
Practice Address - Street 1:1070 N 9TH ST
Practice Address - Street 2:
Practice Address - City:STROUDSBURG
Practice Address - State:PA
Practice Address - Zip Code:18360-1210
Practice Address - Country:US
Practice Address - Phone:570-517-5048
Practice Address - Fax:570-517-0974
Is Sole Proprietor?:No
Enumeration Date:2005-11-16
Last Update Date:2007-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY009813363A00000X
PAMA051295363A00000X
MI5601002969363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02566163Medicaid
Q06820Medicare UPIN
NYPA0234Medicare ID - Type Unspecified