Provider Demographics
NPI:1194716340
Name:KING, JODY L (PA)
Entity type:Individual
Prefix:MR
First Name:JODY
Middle Name:L
Last Name:KING
Suffix:
Gender:M
Credentials:PA
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Mailing Address - Street 1:2800 VILLAGE WAY
Mailing Address - Street 2:
Mailing Address - City:TRENT WOODS
Mailing Address - State:NC
Mailing Address - Zip Code:28562-7305
Mailing Address - Country:US
Mailing Address - Phone:252-637-7300
Mailing Address - Fax:252-637-1772
Practice Address - Street 1:2800 VILLAGE WAY
Practice Address - Street 2:
Practice Address - City:TRENT WOODS
Practice Address - State:NC
Practice Address - Zip Code:28562-7305
Practice Address - Country:US
Practice Address - Phone:252-637-7300
Practice Address - Fax:252-637-1772
Is Sole Proprietor?:No
Enumeration Date:2005-11-04
Last Update Date:2008-05-19
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NC0010-00274363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC891036CMedicaid
NC1036COtherBLUE CROSS BLUE SHIELD