Provider Demographics
NPI:1790053338
Name:KING, AMANDA D (NP)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:D
Last Name:KING
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3340 E GOLDSTONE DR
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642
Mailing Address - Country:US
Mailing Address - Phone:208-302-5950
Mailing Address - Fax:208-302-5955
Practice Address - Street 1:10583 W LAKE HAZEL RD
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83709
Practice Address - Country:US
Practice Address - Phone:208-302-5950
Practice Address - Fax:208-302-5955
Is Sole Proprietor?:No
Enumeration Date:2011-12-10
Last Update Date:2020-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDN-41966163W00000X
IDGNP26011A363L00000X
IDNP-1345A363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1790053338Medicaid
ID20003951Medicare PIN
ID20003949Medicare PIN
ID1790053338Medicaid
ID20003952Medicare PIN
ID20003948Medicare PIN