Provider Demographics
NPI:1699099911
Name:KING, MICHAEL DON (NURSE PRACTITIONER)
Entity type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:DON
Last Name:KING
Suffix:
Gender:M
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 981
Mailing Address - Street 2:
Mailing Address - City:OXFORD
Mailing Address - State:MS
Mailing Address - Zip Code:38655-0981
Mailing Address - Country:US
Mailing Address - Phone:662-983-0139
Mailing Address - Fax:
Practice Address - Street 1:188 W OXFORD ST
Practice Address - Street 2:
Practice Address - City:PONTOTOC
Practice Address - State:MS
Practice Address - Zip Code:38863-2006
Practice Address - Country:US
Practice Address - Phone:662-983-0139
Practice Address - Fax:662-796-3190
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-15
Last Update Date:2018-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR654388363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS06707899Medicaid
MS302I508707Medicare PIN