Provider Demographics
NPI:1588962419
Name:KING, BENJAMIN RICHARD (CRNA)
Entity type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:RICHARD
Last Name:KING
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:801 W MAPLE ST
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:NM
Mailing Address - Zip Code:87401-5630
Mailing Address - Country:US
Mailing Address - Phone:505-609-2000
Mailing Address - Fax:
Practice Address - Street 1:1515 E 20TH ST
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:NM
Practice Address - Zip Code:87401-9039
Practice Address - Country:US
Practice Address - Phone:505-326-6400
Practice Address - Fax:505-326-4606
Is Sole Proprietor?:No
Enumeration Date:2011-03-01
Last Update Date:2011-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMCRNA-01133367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM07957866Medicaid
UT1588962419Medicaid
AZ601683Medicaid
CO82373370Medicaid
NM07957866Medicaid