Provider Demographics
NPI:1851055867
Name:MCKIDDY, SHAWN LEE
Entity Type:Individual
Prefix:
First Name:SHAWN
Middle Name:LEE
Last Name:MCKIDDY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:542 OLD WILKES RD
Mailing Address - Street 2:
Mailing Address - City:GLENDALE SPRINGS
Mailing Address - State:NC
Mailing Address - Zip Code:28629-9103
Mailing Address - Country:US
Mailing Address - Phone:336-977-0290
Mailing Address - Fax:
Practice Address - Street 1:542 OLD WILKES RD
Practice Address - Street 2:
Practice Address - City:GLENDALE SPRINGS
Practice Address - State:NC
Practice Address - Zip Code:28629-9103
Practice Address - Country:US
Practice Address - Phone:336-977-0290
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-26
Last Update Date:2021-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program