Provider Demographics
NPI:1770573644
Name:KING, DARRELL L (PA)
Entity type:Individual
Prefix:
First Name:DARRELL
Middle Name:L
Last Name:KING
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 W. FORT STREET
Mailing Address - Street 2:BOISE VA
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83702-4501
Mailing Address - Country:US
Mailing Address - Phone:208-422-1136
Mailing Address - Fax:208-422-1083
Practice Address - Street 1:500 W. FORT STREET
Practice Address - Street 2:BOISE VA
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83702-4501
Practice Address - Country:US
Practice Address - Phone:208-422-1136
Practice Address - Fax:208-422-1083
Is Sole Proprietor?:No
Enumeration Date:2005-10-24
Last Update Date:2012-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPA235363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID970029609OtherRR MEDICARE
ID000010141117OtherBCBS
IDPADA5OtherBCBS
ID000010141122OtherBCBS
IDPADB3OtherBCBS
ID805341400Medicaid
ID805341400Medicaid
ID1665610Medicare ID - Type Unspecified