MEDICARE: MRS. KIMBERLY BETH SIDERS PA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	PA9103918	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1104905751
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. KIMBERLY BETH SIDERS PA-C

Provider Business Mailing Address
First Line	:	15051 S TAMIAMI TRL
Second Line	:	SUITE 203
City	:	FORT MYERS
State	:	FL
Zip	:	33908-5182
Country	:	US
Telephone Number	:	239-437-8810
Fax Number	:	239-313-2555

Provider Business Practice Location Address
First Line	:	15310 AMBERLY DR
Second Line	:	SUITE 150
City	:	TAMPA
State	:	FL
Zip	:	33647-2199
Country	:	US
Telephone Number	:	813-978-8888
Fax Number	:	813-972-8974

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/03/2006
Last Update Date	:	03/10/2017

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Directions to “ MRS. KIMBERLY BETH SIDERS PA-C” Practice Location

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