Provider Demographics
NPI:1790754463
Name:KING, JERRY J (PA-C)
Entity Type:Individual
Prefix:
First Name:JERRY
Middle Name:J
Last Name:KING
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2831 FORT MISSOULA RD
Mailing Address - Street 2:SUITE 232
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59804-7419
Mailing Address - Country:US
Mailing Address - Phone:406-728-6101
Mailing Address - Fax:406-721-3278
Practice Address - Street 1:2831 FORT MISSOULA RD
Practice Address - Street 2:SUITE 232
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59804-7419
Practice Address - Country:US
Practice Address - Phone:406-728-6101
Practice Address - Fax:406-721-3278
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT770597363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT0023283Medicaid
MT8585Medicare ID - Type Unspecified
MT0023283Medicaid