Provider Demographics
NPI:1851616916
Name:KIDD, SHANNA (PA-C)
Entity Type:Individual
Prefix:
First Name:SHANNA
Middle Name:
Last Name:KIDD
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:SHANNA
Other - Middle Name:JO
Other - Last Name:WHEATLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:701 W 5TH ST
Mailing Address - Street 2:SUITE 1C34
Mailing Address - City:ODESSA
Mailing Address - State:TX
Mailing Address - Zip Code:79763-4206
Mailing Address - Country:US
Mailing Address - Phone:432-335-5126
Mailing Address - Fax:432-335-1807
Practice Address - Street 1:701 W 5TH ST
Practice Address - Street 2:
Practice Address - City:ODESSA
Practice Address - State:TX
Practice Address - Zip Code:79763-4206
Practice Address - Country:US
Practice Address - Phone:432-335-1500
Practice Address - Fax:432-335-1537
Is Sole Proprietor?:No
Enumeration Date:2010-04-01
Last Update Date:2010-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA06691363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant