Provider Demographics
NPI:1295866820
Name:KIDA, ERIKO (PA)
Entity Type:Individual
Prefix:MS
First Name:ERIKO
Middle Name:
Last Name:KIDA
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:645 W 239TH ST
Mailing Address - Street 2:3G
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10463-1234
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:111 E 210TH ST
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10467-2401
Practice Address - Country:US
Practice Address - Phone:718-920-7401
Practice Address - Fax:718-920-2058
Is Sole Proprietor?:No
Enumeration Date:2007-03-07
Last Update Date:2008-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY007150-1363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00245643Medicaid