Provider Demographics
NPI:1659525681
Name:NIDA, KENNETH EDWARD (PA)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:EDWARD
Last Name:NIDA
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 9671
Mailing Address - Street 2:
Mailing Address - City:DAYTONA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32120-9671
Mailing Address - Country:US
Mailing Address - Phone:386-676-7130
Mailing Address - Fax:386-676-7125
Practice Address - Street 1:320 N CLYDE MORRIS BLVD
Practice Address - Street 2:
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32114-2744
Practice Address - Country:US
Practice Address - Phone:386-238-3293
Practice Address - Fax:386-238-3223
Is Sole Proprietor?:No
Enumeration Date:2008-11-04
Last Update Date:2015-06-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLPA 9107756363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLY0Q8MOtherBCBS
FL014260400Medicaid
FL1659525681OtherTRICARE
FLIB804ZMedicare PIN