=====================================================
General NPI Number Information
=====================================================
NPI Number | 1750024741
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SCOTTY KING APRN, FNP-C
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/18/2022
-----------------------------------------------------
Last Update Date | 05/16/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 212 E 8TH ST
-----------------------------------------------------
City | BEAVER
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73932-3184
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 580-625-4551
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 640
-----------------------------------------------------
City | BEAVER
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73932-0640
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 580-625-4551
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 207607
-----------------------------------------------------
License Number State | OK
-----------------------------------------------------