Healthcare Provider Details

I. General information

NPI: 1740279884
Provider Name (Legal Business Name): JUSTIN L KIDD PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/20/2005
Last Update Date: 04/22/2026
Certification Date: 04/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1633 MEDICAL CENTER PT
COLORADO SPRINGS CO
80907-5700
US

IV. Provider business mailing address

PO BOX 35380
LAS VEGAS NV
89133-5380
US

V. Phone/Fax

Practice location:
  • Phone: 719-473-6155
  • Fax: 719-473-3688
Mailing address:
  • Phone: 702-579-3253
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA.0003632
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: