Basic Information
| Provider Information | |||||||||
| NPI: | 1255423364 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KING | ||||||||
| FirstName: | GREGORY | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | APRN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 403 WOODLAND HILLS BLVD | ||||||||
| Address2: | |||||||||
| City: | FORT SCOTT | ||||||||
| State: | KS | ||||||||
| PostalCode: | 667018798 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6202238040 | ||||||||
| FaxNumber: | 6202238002 | ||||||||
| Practice Location | |||||||||
| Address1: | 403 WOODLAND HILLS BLVD | ||||||||
| Address2: | |||||||||
| City: | FORT SCOTT | ||||||||
| State: | KS | ||||||||
| PostalCode: | 667018798 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6202238040 | ||||||||
| FaxNumber: | 6202238002 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/28/2006 | ||||||||
| LastUpdateDate: | 11/06/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/06/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 44801 | KS | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 100351090B | 05 | KS | MEDICAID |