Basic Information
| Provider Information | |||||||||
| NPI: | 1174563837 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KING | ||||||||
| FirstName: | CARL | ||||||||
| MiddleName: | EDWARD | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3024 BUSINESS PARK CIR | ||||||||
| Address2: | |||||||||
| City: | GOODLETTSVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370723132 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6158516033 | ||||||||
| FaxNumber: | 6158512018 | ||||||||
| Practice Location | |||||||||
| Address1: | 131 FRENCH LANDING DR | ||||||||
| Address2: | |||||||||
| City: | NASHVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 372281511 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6152549981 | ||||||||
| FaxNumber: | 6152549747 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/08/2006 | ||||||||
| LastUpdateDate: | 05/10/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 683 | SC | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | 516 | TN | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 3669278 | 05 | TN | MEDICAID | 6067427 | 01 | TN | BCBS TN | OTHER | Q004744 | 05 | TN | MEDICAID |