Provider Demographics
NPI:1609839836
Name:KING, JOHN R (CRNA)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:R
Last Name:KING
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 896138
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28289-6138
Mailing Address - Country:US
Mailing Address - Phone:423-639-0941
Mailing Address - Fax:423-638-3401
Practice Address - Street 1:300 BILLINGSLEY RD STE 200
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28211-1180
Practice Address - Country:US
Practice Address - Phone:704-372-7974
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-10
Last Update Date:2022-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN10355367500000X
TNRN0000131100367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3633770Medicaid
TN4102708OtherBC/BS
TN3633770Medicare PIN
TN4102708OtherBC/BS