Provider Demographics
NPI:1962466532
Name:KIDMAN, RICKY L (PA-C)
Entity Type:Individual
Prefix:
First Name:RICKY
Middle Name:L
Last Name:KIDMAN
Suffix:
Gender:M
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 1:300 SINGLETON RIDGE RD
Mailing Address - Street 2:ATTENTION PNS CREDENTIALING
Mailing Address - City:CONWAY
Mailing Address - State:SC
Mailing Address - Zip Code:29526-9142
Mailing Address - Country:US
Mailing Address - Phone:843-234-6946
Mailing Address - Fax:
Practice Address - Street 1:51 11TH AVENUE
Practice Address - Street 2:
Practice Address - City:AYNOR
Practice Address - State:SC
Practice Address - Zip Code:29511-3249
Practice Address - Country:US
Practice Address - Phone:843-358-3700
Practice Address - Fax:843-358-3707
Is Sole Proprietor?:No
Enumeration Date:2006-04-12
Last Update Date:2023-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1094363AM0700X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC1140PAMedicaid
SCAA1581Medicare UPIN
SCGP5462Medicaid
SC3706Medicare PIN