Provider Demographics
NPI:1306337555
Name:KING, KOLETTE (PA-C)
Entity type:Individual
Prefix:
First Name:KOLETTE
Middle Name:
Last Name:KING
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 PENNSYLVANIA AVE SE
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20003-4316
Mailing Address - Country:US
Mailing Address - Phone:202-839-3459
Mailing Address - Fax:202-839-3459
Practice Address - Street 1:600 PENNSYLVANIA AVE SE
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20003-4316
Practice Address - Country:US
Practice Address - Phone:202-839-3459
Practice Address - Fax:202-839-3459
Is Sole Proprietor?:No
Enumeration Date:2018-05-23
Last Update Date:2024-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA18-53495106S00000X
363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician