=====================================================
General NPI Number Information
=====================================================
NPI Number | 1033447313
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BRANDON VIRDELL KING CSA, CSFA
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/25/2009
-----------------------------------------------------
Last Update Date | 11/24/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 55 ATLANTA ST SE STE 204
-----------------------------------------------------
City | MARIETTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30060-1977
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 678-517-3428
-----------------------------------------------------
Fax | 770-485-1534
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 81
-----------------------------------------------------
City | MARIETTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30061-0081
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 678-517-3428
-----------------------------------------------------
Fax | 770-485-1534
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363AS0400X
-----------------------------------------------------
Taxonomy Name | Surgical Physician Assistant
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------