Provider Demographics
NPI:1972357739
Name:KIDD, ETHAN SHANE
Entity Type:Individual
Prefix:
First Name:ETHAN
Middle Name:SHANE
Last Name:KIDD
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 1:6128 E 38TH ST
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74135-5832
Mailing Address - Country:US
Mailing Address - Phone:918-779-7144
Mailing Address - Fax:918-663-0203
Practice Address - Street 1:6128 E 38TH ST
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74135-5832
Practice Address - Country:US
Practice Address - Phone:918-779-7144
Practice Address - Fax:918-663-0203
Is Sole Proprietor?:No
Enumeration Date:2024-04-16
Last Update Date:2024-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist