Provider Demographics
NPI:1710422084
Name:KIDERA, DEIRDRE MAY (PA-C)
Entity Type:Individual
Prefix:
First Name:DEIRDRE
Middle Name:MAY
Last Name:KIDERA
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 1:3591 HIPSLEY MILL RD
Mailing Address - Street 2:
Mailing Address - City:WOODBINE
Mailing Address - State:MD
Mailing Address - Zip Code:21797-7613
Mailing Address - Country:US
Mailing Address - Phone:410-608-5713
Mailing Address - Fax:
Practice Address - Street 1:1500 FOREST GLEN RD
Practice Address - Street 2:
Practice Address - City:SILVER SPRING
Practice Address - State:MD
Practice Address - Zip Code:20910-1460
Practice Address - Country:US
Practice Address - Phone:301-754-7000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-12-22
Last Update Date:2016-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC0006318363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant