Olivia Mackenzie King, PA

Primary specialty

Physician AssistantTaxonomy code 363A00000X

Practice address

4322 Lafayette Blvd.
South Bend, IN 46614

Phone

(574) 391-1111

Fax

(574) 859-5040

NPI assigned

Aug 26, 2024

Sex

Female

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Medicare fee-for-service enrollment

Enrolled in IN

Eligible to order & refer

• Part B services: Yes
• Medical equipment: Yes
• Home health: Yes
• Power mobility devices: Yes
• Hospice: No

Green means eligible to order or refer.

Enrollment records 1

Specialty

Physician Assistant

Education

Other, 2024

Medicare assignment

Accepts the Medicare-approved amount as payment in full

Group practices

Cardinal Dermatology LLCGroup PAC ID 0042741746, 6 clinicians

Practice addresses (Care Compare)

Medicare enrollment (NPD)

Enrolled

Credentials

Physician Assistant

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

• Cardinal Dermatology LLC

  • Dermatology Physician
  • South Bend, IN
  • NPI 1174390926
  Medicare reassignment Care Compare group

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1724630400000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1724630400000",
    "number": "1366276149",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "4322 LAFAYETTE BLVD.",
            "city": "SOUTH BEND",
            "state": "IN",
            "postal_code": "46614",
            "telephone_number": "574-391-1111",
            "fax_number": "574-859-5040"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "4322 LAFAYETTE BLVD.",
            "city": "SOUTH BEND",
            "state": "IN",
            "postal_code": "46614",
            "telephone_number": "574-391-1111",
            "fax_number": "574-859-5040"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "KING",
        "first_name": "OLIVIA",
        "middle_name": "MACKENZIE",
        "name_prefix": "Mrs.",
        "credential": "PA",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2024-08-26",
        "last_updated": "2024-08-26",
        "certification_date": "2024-08-01",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "363A00000X",
            "taxonomy_group": "",
            "desc": "Physician Assistant",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Jessica A Kindig, LMHC
• Cynthia Rene'a King-Harris, M.S.,L.M.H.C.
• Adriana King
• Alyssa Rose King
• Olivia King
• Robert Bruce King, MD
• Robert Preston King, M.D.
• Zaria King
• Reuben Kingamkono
• Daniel Matthew Kinney, MD

• Physician Assistant in South Bend, IN
• Providers in South Bend, IN by specialty
• Physician Assistant in Indiana

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 26, 2024; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
• Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.