Provider Demographics
NPI:1154621613
Name:JUDITH A KING MN FNP PC
Entity type:Organization
Organization Name:JUDITH A KING MN FNP PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PROVIDER
Authorized Official - Prefix:MS
Authorized Official - First Name:JUDITH
Authorized Official - Middle Name:A
Authorized Official - Last Name:KING
Authorized Official - Suffix:
Authorized Official - Credentials:FAMILY NURSE PRACTIT
Authorized Official - Phone:541-474-5665
Mailing Address - Street 1:124 NW MIDLAND AVE STE 107
Mailing Address - Street 2:
Mailing Address - City:GRANTS PASS
Mailing Address - State:OR
Mailing Address - Zip Code:97526-1269
Mailing Address - Country:US
Mailing Address - Phone:541-474-5665
Mailing Address - Fax:541-474-4435
Practice Address - Street 1:124 NW MIDLAND AVE
Practice Address - Street 2:
Practice Address - City:GRANTS PASS
Practice Address - State:OR
Practice Address - Zip Code:97526-1269
Practice Address - Country:US
Practice Address - Phone:541-474-5665
Practice Address - Fax:541-474-4435
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-29
Last Update Date:2010-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR000037306N1363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR900109622OtherMEDICARE RR
OR108613OtherMEDICARE ID-TYPE UNSPECIFIED
R108613OtherMEDICARE
OR074450Medicaid
ORS02931Medicare UPIN