Provider Demographics
NPI:1619598620
Name:KING, JUSTIN M (PA)
Entity type:Individual
Prefix:
First Name:JUSTIN
Middle Name:M
Last Name:KING
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1932 ALCOA HWY
Mailing Address - Street 2:STE 360
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37920-1509
Mailing Address - Country:US
Mailing Address - Phone:865-524-1869
Mailing Address - Fax:865-544-6533
Practice Address - Street 1:102 DUNHILL PL NW
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:TN
Practice Address - Zip Code:37311-3885
Practice Address - Country:US
Practice Address - Phone:423-339-9581
Practice Address - Fax:423-472-0494
Is Sole Proprietor?:No
Enumeration Date:2020-04-30
Last Update Date:2020-08-13
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TN4112363AS0400X
363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNPA4112OtherNCCPA