Provider Demographics
NPI:1639879703
Name:KING, KORTREZ (NP)
Entity Type:Individual
Prefix:
First Name:KORTREZ
Middle Name:
Last Name:KING
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:876 SEMINOLE RD
Mailing Address - Street 2:
Mailing Address - City:NORTON SHORES
Mailing Address - State:MI
Mailing Address - Zip Code:49441-4340
Mailing Address - Country:US
Mailing Address - Phone:231-903-2044
Mailing Address - Fax:
Practice Address - Street 1:876 SEMINOLE RD
Practice Address - Street 2:
Practice Address - City:NORTON SHORES
Practice Address - State:MI
Practice Address - Zip Code:49441-4340
Practice Address - Country:US
Practice Address - Phone:231-903-2044
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-07
Last Update Date:2024-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704319078163W00000X
MI4704319078NSA2304W363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
No163W00000XNursing Service ProvidersRegistered Nurse