Provider Demographics
NPI:1760822084
Name:KING, GEORGE KEITH (FNP)
Entity Type:Individual
Prefix:
First Name:GEORGE
Middle Name:KEITH
Last Name:KING
Suffix:
Gender:M
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:919 HIDDEN RDG
Mailing Address - Street 2:
Mailing Address - City:IRVING
Mailing Address - State:TX
Mailing Address - Zip Code:75038-3813
Mailing Address - Country:US
Mailing Address - Phone:469-282-2711
Mailing Address - Fax:469-282-2609
Practice Address - Street 1:307 BUCKEYE RIDGE LOOP
Practice Address - Street 2:
Practice Address - City:DEVILLE
Practice Address - State:LA
Practice Address - Zip Code:71328-8515
Practice Address - Country:US
Practice Address - Phone:318-613-4762
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-01
Last Update Date:2019-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAAP07397363LF0000X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2369199Medicaid
LA2369199Medicaid