Provider Demographics
NPI:1821624370
Name:KING, MARY R (PA-C)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:R
Last Name:KING
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11295 E TAYLOR RD
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39503-4197
Mailing Address - Country:US
Mailing Address - Phone:228-864-3300
Mailing Address - Fax:228-864-3333
Practice Address - Street 1:11295 E TAYLOR RD
Practice Address - Street 2:
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39503-4197
Practice Address - Country:US
Practice Address - Phone:228-864-3300
Practice Address - Fax:228-864-3333
Is Sole Proprietor?:No
Enumeration Date:2020-03-17
Last Update Date:2023-05-25
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
ALPA.1595363A00000X
MSPA00646363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant