Provider Demographics
NPI:1457125916
Name:RUIZ CARRILLO, KYDIA
Entity type:Individual
Prefix:
First Name:KYDIA
Middle Name:
Last Name:RUIZ CARRILLO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25 JOHN ALY
Mailing Address - Street 2:
Mailing Address - City:COOPERSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:18036-1950
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5300 KIDSPEACE DR
Practice Address - Street 2:
Practice Address - City:OREFIELD
Practice Address - State:PA
Practice Address - Zip Code:18069-2000
Practice Address - Country:US
Practice Address - Phone:800-854-3123
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-14
Last Update Date:2023-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA064914363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant