Provider Demographics
NPI:1003338278
Name:KIDDER, LEAH (PA-C)
Entity Type:Individual
Prefix:
First Name:LEAH
Middle Name:
Last Name:KIDDER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 601
Mailing Address - Street 2:
Mailing Address - City:DANSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:14437-0601
Mailing Address - Country:US
Mailing Address - Phone:585-335-3100
Mailing Address - Fax:
Practice Address - Street 1:25 PARK AVE
Practice Address - Street 2:
Practice Address - City:COHOCTON
Practice Address - State:NY
Practice Address - Zip Code:14826-9401
Practice Address - Country:US
Practice Address - Phone:585-384-5310
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-10
Last Update Date:2021-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY020888207QA0000X, 208600000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No207QA0000XAllopathic & Osteopathic PhysiciansFamily MedicineAdolescent Medicine
No208600000XAllopathic & Osteopathic PhysiciansSurgery