Provider Demographics
NPI:1992839575
Name:KIDD, KRISTEN LYNNE (PA-C)
Entity Type:Individual
Prefix:MISS
First Name:KRISTEN
Middle Name:LYNNE
Last Name:KIDD
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 636988
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45263-6988
Mailing Address - Country:US
Mailing Address - Phone:888-940-2722
Mailing Address - Fax:513-632-8898
Practice Address - Street 1:1044 BELMONT AVE
Practice Address - Street 2:
Practice Address - City:YOUNGSTOWN
Practice Address - State:OH
Practice Address - Zip Code:44504-1006
Practice Address - Country:US
Practice Address - Phone:330-480-3709
Practice Address - Fax:330-480-2568
Is Sole Proprietor?:No
Enumeration Date:2007-03-15
Last Update Date:2015-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50-001735363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0084823Medicaid
OHP93569Medicare UPIN