Provider Demographics
NPI:1811930134
Name:KING, MARCUS SHANNON (PT ATC LAT)
Entity type:Individual
Prefix:
First Name:MARCUS
Middle Name:SHANNON
Last Name:KING
Suffix:
Gender:M
Credentials:PT ATC LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6399 GOODMAN RD
Mailing Address - Street 2:SUITE 108
Mailing Address - City:OLIVE BRANCH
Mailing Address - State:MS
Mailing Address - Zip Code:38654-7070
Mailing Address - Country:US
Mailing Address - Phone:901-652-0413
Mailing Address - Fax:
Practice Address - Street 1:6399 GOODMAN RD
Practice Address - Street 2:SUITE 108
Practice Address - City:OLIVE BRANCH
Practice Address - State:MS
Practice Address - Zip Code:38654-7070
Practice Address - Country:US
Practice Address - Phone:901-652-0413
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-14
Last Update Date:2025-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPT2745225100000X
MSAT03832255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAP00190587OtherMEDICARE RAILROAD PIN
MS00125663Medicaid
GADC7950OtherMEDICARE RAILROAD GROUP
MS00125663Medicaid
MSC03193Medicare ID - Type UnspecifiedGROUP