Provider Demographics
NPI:1861665275
Name:KING, KERI RUSSELL (PA)
Entity Type:Individual
Prefix:
First Name:KERI
Middle Name:RUSSELL
Last Name:KING
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5957 DALLAS PKWY
Mailing Address - Street 2:SUITE100
Mailing Address - City:PLANO
Mailing Address - State:TX
Mailing Address - Zip Code:75093-7822
Mailing Address - Country:US
Mailing Address - Phone:972-596-2552
Mailing Address - Fax:972-964-7209
Practice Address - Street 1:5957 DALLAS PKWY
Practice Address - Street 2:SUITE100
Practice Address - City:PLANO
Practice Address - State:TX
Practice Address - Zip Code:75093-7822
Practice Address - Country:US
Practice Address - Phone:972-596-2552
Practice Address - Fax:972-964-7209
Is Sole Proprietor?:No
Enumeration Date:2008-04-07
Last Update Date:2008-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA05090363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical