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: 12/05/2024
Certification Date: 12/05/2024
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:
Mailing address:
  • Phone: 719-463-5600
  • Fax: 719-538-8290

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number003902
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberPA-003632
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: