Basic Information
| Provider Information | |||||||||
| NPI: | 1356618359 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KING | ||||||||
| FirstName: | KRYSTAL | ||||||||
| MiddleName: | ANN | ||||||||
| NamePrefix: | MISS | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 736 ROUTE 4 | ||||||||
| Address2: | STE. 103 | ||||||||
| City: | SINAJANA | ||||||||
| State: | GUAM | ||||||||
| PostalCode: | 96910 | ||||||||
| CountryCode: | UM | ||||||||
| TelephoneNumber: | 6716497232 | ||||||||
| FaxNumber: | 6716497233 | ||||||||
| Practice Location | |||||||||
| Address1: | 736 ROUTE 4 | ||||||||
| Address2: | STE. 103 | ||||||||
| City: | SINAJANA | ||||||||
| State: | GUAM | ||||||||
| PostalCode: | 96910 | ||||||||
| CountryCode: | UM | ||||||||
| TelephoneNumber: | 6716497232 | ||||||||
| FaxNumber: | 6716497233 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/19/2011 | ||||||||
| LastUpdateDate: | 07/28/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA-83 | GU | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.