Provider Demographics
NPI:1396842480
Name:KIDD, LAURA R (PA)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:R
Last Name:KIDD
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:LAURA
Other - Middle Name:R
Other - Last Name:WILLENBORG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:305 W JACKSON ST STE 200
Mailing Address - Street 2:
Mailing Address - City:CARBONDALE
Mailing Address - State:IL
Mailing Address - Zip Code:62901-1474
Mailing Address - Country:US
Mailing Address - Phone:618-536-6621
Mailing Address - Fax:618-453-1102
Practice Address - Street 1:305 W JACKSON ST STE 200
Practice Address - Street 2:
Practice Address - City:CARBONDALE
Practice Address - State:IL
Practice Address - Zip Code:62901-1474
Practice Address - Country:US
Practice Address - Phone:618-536-6621
Practice Address - Fax:618-453-1102
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085.002750363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL085-002750OtherPHYSICIAN ASSISTANT LICENSE
IL085-002750OtherPHYSICIAN ASSISTANT LICENSE
IL209286Medicare PIN
ILR03045Medicare PIN