Provider Demographics
NPI:1093939183
Name:KIDD, JASON S (PA-C)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:S
Last Name:KIDD
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:PO BOX 217
Mailing Address - Street 2:
Mailing Address - City:ROCK CAVE
Mailing Address - State:WV
Mailing Address - Zip Code:26234-0217
Mailing Address - Country:US
Mailing Address - Phone:304-924-6262
Mailing Address - Fax:304-924-5460
Practice Address - Street 1:924 LIBERTY STREET
Practice Address - Street 2:
Practice Address - City:WEST MILFORD
Practice Address - State:WV
Practice Address - Zip Code:26451
Practice Address - Country:US
Practice Address - Phone:304-745-4568
Practice Address - Fax:304-326-3700
Is Sole Proprietor?:No
Enumeration Date:2007-04-12
Last Update Date:2013-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV01023363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810010365Medicaid
WV3810010365Medicaid
WVPA23253Medicare PIN
WV2030133Medicare PIN
WV2030132Medicare PIN
WV2031132Medicare PIN
WV2031131Medicare PIN