Provider Demographics
NPI:1245481985
Name:KING, LUTHER W (PA)
Entity type:Individual
Prefix:MR
First Name:LUTHER
Middle Name:W
Last Name:KING
Suffix:
Gender:M
Credentials:PA
Other - Prefix:MR
Other - First Name:LUTHER
Other - Middle Name:W
Other - Last Name:KING
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PA
Mailing Address - Street 1:2175 ROSALINE AVENUE
Mailing Address - Street 2:
Mailing Address - City:REDDING
Mailing Address - State:CA
Mailing Address - Zip Code:96001-2509
Mailing Address - Country:US
Mailing Address - Phone:530-225-6000
Mailing Address - Fax:
Practice Address - Street 1:2175 ROSALINE AVENUE
Practice Address - Street 2:
Practice Address - City:REDDING
Practice Address - State:CA
Practice Address - Zip Code:96001-2509
Practice Address - Country:US
Practice Address - Phone:530-225-6000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-30
Last Update Date:2008-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA14501363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPA14501OtherSTATE OF CALIFORNIA
CAPA14501OtherSTATE OF CALIFORNIA