MEDICARE: KELLIE KING PA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	PA2072	NV
2	363A00000X	Physician Assistant	PA15260	TX

General Provider Information

NPI Number	:	1245707090
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KELLIE KING PA-C

Provider Business Mailing Address
First Line	:	2925 BRIARPARK DR STE 575
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77042-3776
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	5211 FM 2920 RD STE 101
Second Line	:
City	:	SPRING
State	:	TX
Zip	:	77388-3004
Country	:	US
Telephone Number	:	281-783-8162
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/30/2018
Last Update Date	:	03/09/2022

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Directions to “ KELLIE KING PA-C” Practice Location

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