Provider Demographics
NPI:1336213826
Name:KING, CLEMENTINE (PA)
Entity Type:Individual
Prefix:
First Name:CLEMENTINE
Middle Name:
Last Name:KING
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
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Mailing Address - Street 1:3050 E AIRPORT WAY
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90806-2404
Mailing Address - Country:US
Mailing Address - Phone:562-426-9661
Mailing Address - Fax:562-426-4227
Practice Address - Street 1:165 W HOSPITALITY LN
Practice Address - Street 2:STE 1
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92408-3334
Practice Address - Country:US
Practice Address - Phone:909-885-0282
Practice Address - Fax:909-889-7367
Is Sole Proprietor?:No
Enumeration Date:2006-11-17
Last Update Date:2023-03-07
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
CA10434363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAMK1139268OtherDEA