Healthcare Provider Details

I. General information

NPI: 1306868880
Provider Name (Legal Business Name): JON D. KING CSA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/24/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4040 COON RAPIDS BLVD NW # 100
COON RAPIDS MN
55433-2522
US

IV. Provider business mailing address

4040 COON RAPIDS BLVD NW # 100
COON RAPIDS MN
55433-2522
US

V. Phone/Fax

Practice location:
  • Phone: 763-236-9500
  • Fax:
Mailing address:
  • Phone: 763-236-9500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246ZS0410X
TaxonomySurgical Technologist
License Number077776
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: