Basic Information
| Provider Information | |||||||||
| NPI: | 1518921964 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KING | ||||||||
| FirstName: | KIMBERLY | ||||||||
| MiddleName: | S | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1333 E BARNETT RD | ||||||||
| Address2: | |||||||||
| City: | MEDFORD | ||||||||
| State: | OR | ||||||||
| PostalCode: | 975048219 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5417794711 | ||||||||
| FaxNumber: | 5417790796 | ||||||||
| Practice Location | |||||||||
| Address1: | 1333 E BARNETT RD | ||||||||
| Address2: | |||||||||
| City: | MEDFORD | ||||||||
| State: | OR | ||||||||
| PostalCode: | 97504 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5417794711 | ||||||||
| FaxNumber: | 5417790796 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/13/2006 | ||||||||
| LastUpdateDate: | 06/25/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 55479 | KS | N | Nursing Service Providers | Registered Nurse | 367500000X | 55479 | KS | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered | 367500000X | 201802897CRNA | OR | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 200363250A | 05 | KS | MEDICAID | 500743849 | 05 | OR | MEDICAID |