Provider Demographics
NPI:1760452130
Name:KING, KELLEY L (PA)
Entity type:Individual
Prefix:
First Name:KELLEY
Middle Name:L
Last Name:KING
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
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Mailing Address - Street 1:10470 OLD PLACERVILLE RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95827-2539
Mailing Address - Country:US
Mailing Address - Phone:800-470-0071
Mailing Address - Fax:
Practice Address - Street 1:4401 BRADSHAW RD
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95827-3835
Practice Address - Country:US
Practice Address - Phone:916-732-5243
Practice Address - Fax:916-366-3206
Is Sole Proprietor?:No
Enumeration Date:2006-01-26
Last Update Date:2018-03-17
Deactivation Date:
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPA17317OtherSTATE LICENSE
CAPA17317OtherSTATE LICENSE
CAQ21540Medicare ID - Type UnspecifiedMEDICARE ID