Provider Demographics
NPI:1912375460
Name:KING, MADELINE L (PA)
Entity Type:Individual
Prefix:
First Name:MADELINE
Middle Name:L
Last Name:KING
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:MADELINE
Other - Middle Name:L
Other - Last Name:CONNLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:3340 E GOLDSTONE WAY
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 1:12273 W MCMILLAN RD
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83713-0555
Practice Address - Country:US
Practice Address - Phone:208-367-6330
Practice Address - Fax:208-367-4765
Is Sole Proprietor?:No
Enumeration Date:2015-09-14
Last Update Date:2018-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPA-1285363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant