Provider Demographics
NPI:1023000122
Name:VIDA, KEVIN A (PA C)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:A
Last Name:VIDA
Suffix:
Gender:M
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:P.O. BOX 1730
Mailing Address - Street 2:
Mailing Address - City:RANCHO MIRAGE
Mailing Address - State:CA
Mailing Address - Zip Code:92270-1058
Mailing Address - Country:US
Mailing Address - Phone:760-568-2684
Mailing Address - Fax:760-837-2202
Practice Address - Street 1:39000 BOB HOPE DRIVE
Practice Address - Street 2:HARRY & DIANE RINKER BUILDING
Practice Address - City:RANCHO MIRAGE
Practice Address - State:CA
Practice Address - Zip Code:92270-3221
Practice Address - Country:US
Practice Address - Phone:760-568-2684
Practice Address - Fax:760-837-2259
Is Sole Proprietor?:No
Enumeration Date:2005-08-16
Last Update Date:2012-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000867363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
S81880Medicare UPIN
CT970000668Medicare ID - Type Unspecified