Provider Demographics
NPI:1720075211
Name:KING, DANIEL CARLETON (PAC)
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:CARLETON
Last Name:KING
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2141 N BEVERLY AVE
Mailing Address - Street 2:STE 101
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85712-2155
Mailing Address - Country:US
Mailing Address - Phone:520-838-0777
Mailing Address - Fax:520-838-0669
Practice Address - Street 1:2141 N BEVERLY AVE
Practice Address - Street 2:STE 101
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85712-2155
Practice Address - Country:US
Practice Address - Phone:520-838-0777
Practice Address - Fax:520-838-0669
Is Sole Proprietor?:No
Enumeration Date:2005-09-30
Last Update Date:2015-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363AM0700X
AZ3603363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR230799Medicaid