Basic Information
| Provider Information | |||||||||
| NPI: | 1598424996 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KING | ||||||||
| FirstName: | SKYLER | ||||||||
| MiddleName: | RYAN | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 205 | ||||||||
| Address2: | |||||||||
| City: | SUN CITY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 925860205 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9512409105 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1800 WESTERN AVE | ||||||||
| Address2: | |||||||||
| City: | SAN BERNARDINO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 924111356 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9094749952 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/13/2021 | ||||||||
| LastUpdateDate: | 12/13/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/14/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA60469 | CA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.