Provider Demographics
NPI:1568732618
Name:MCKIDDY, CRYSTAL (PA)
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:
Last Name:MCKIDDY
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 1:82 EDGEWOOD DR
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSBURG
Mailing Address - State:KY
Mailing Address - Zip Code:40769-1559
Mailing Address - Country:US
Mailing Address - Phone:423-215-2002
Mailing Address - Fax:
Practice Address - Street 1:14662 N US HIGHWAY 25 E
Practice Address - Street 2:
Practice Address - City:CORBIN
Practice Address - State:KY
Practice Address - Zip Code:40701-6425
Practice Address - Country:US
Practice Address - Phone:606-526-9005
Practice Address - Fax:606-526-8606
Is Sole Proprietor?:No
Enumeration Date:2012-01-06
Last Update Date:2024-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN2075363A00000X
KYPA1887363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1527317Medicaid