Provider Demographics
NPI:1538492509
Name:TIDD, CAROLYN RAE (PA-C)
Entity Type:Individual
Prefix:
First Name:CAROLYN
Middle Name:RAE
Last Name:TIDD
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 1:2249 STATE ROUTE 86 STE 2
Mailing Address - Street 2:
Mailing Address - City:SARANAC LAKE
Mailing Address - State:NY
Mailing Address - Zip Code:12983-5644
Mailing Address - Country:US
Mailing Address - Phone:518-354-5353
Mailing Address - Fax:518-354-8153
Practice Address - Street 1:2249 STATE ROUTE 86 STE 2
Practice Address - Street 2:
Practice Address - City:SARANAC LAKE
Practice Address - State:NY
Practice Address - Zip Code:12983-5644
Practice Address - Country:US
Practice Address - Phone:518-354-5353
Practice Address - Fax:518-354-8153
Is Sole Proprietor?:No
Enumeration Date:2009-09-09
Last Update Date:2019-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY013307363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY013307OtherSTATE LICENSE