Basic Information
| Provider Information | |||||||||
| NPI: | 1578545497 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KING | ||||||||
| FirstName: | KATHRINE | ||||||||
| MiddleName: | ANN | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2107 EATON AVE | ||||||||
| Address2: | |||||||||
| City: | BETHLEHEM | ||||||||
| State: | PA | ||||||||
| PostalCode: | 180182005 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6105704172 | ||||||||
| FaxNumber: | 5705170974 | ||||||||
| Practice Location | |||||||||
| Address1: | 1070 N 9TH ST | ||||||||
| Address2: | |||||||||
| City: | STROUDSBURG | ||||||||
| State: | PA | ||||||||
| PostalCode: | 183601210 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5705175048 | ||||||||
| FaxNumber: | 5705170974 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/16/2005 | ||||||||
| LastUpdateDate: | 11/15/2007 | ||||||||
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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 | 009813 | NY | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | MA051295 | PA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | 5601002969 | MI | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 02566163 | 05 | NY | MEDICAID |