MEDICARE: CLEMENTINE KING PA

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	10434	CA

General Provider Information

NPI Number	:	1336213826
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CLEMENTINE KING PA

Provider Business Mailing Address
First Line	:	3050 E AIRPORT WAY
Second Line	:
City	:	LONG BEACH
State	:	CA
Zip	:	90806-2404
Country	:	US
Telephone Number	:	562-426-9661
Fax Number	:	562-426-4227

Provider Business Practice Location Address
First Line	:	165 W HOSPITALITY LN
Second Line	:	STE 1
City	:	SAN BERNARDINO
State	:	CA
Zip	:	92408-3334
Country	:	US
Telephone Number	:	909-885-0282
Fax Number	:	909-889-7367

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

Provider Enumeration Date	:	11/17/2006
Last Update Date	:	03/07/2023

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Directions to “ CLEMENTINE KING PA” Practice Location

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