Provider Demographics
NPI:1023029931
Name:KING, THU-TRANG CLEO THI (PA)
Entity type:Individual
Prefix:MRS
First Name:THU-TRANG CLEO
Middle Name:THI
Last Name:KING
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:CLEO
Other - Middle Name:
Other - Last Name:KING
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PA
Mailing Address - Street 1:55 CRESENT PT
Mailing Address - Street 2:
Mailing Address - City:GILBERTSVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:42044-8824
Mailing Address - Country:US
Mailing Address - Phone:615-337-7180
Mailing Address - Fax:
Practice Address - Street 1:2501 KENTUCKY AVE
Practice Address - Street 2:
Practice Address - City:PADUCAH
Practice Address - State:KY
Practice Address - Zip Code:42003-3813
Practice Address - Country:US
Practice Address - Phone:270-575-2180
Practice Address - Fax:270-575-8479
Is Sole Proprietor?:No
Enumeration Date:2006-08-10
Last Update Date:2019-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYPA962363A00000X, 363AM0700X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100032090Medicaid
KY7100032090Medicaid