Healthcare Provider Details

I. General information

NPI: 1780140954
Provider Name (Legal Business Name): AMANDA KIDDER PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/13/2019
Last Update Date: 08/18/2025
Certification Date: 08/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 S YORK ST STE 2000
ELMHURST IL
60126-5634
US

IV. Provider business mailing address

2650 RIDGE AVE STE 1223
EVANSTON IL
60201-1700
US

V. Phone/Fax

Practice location:
  • Phone: 630-646-7000
  • Fax: 331-221-2760
Mailing address:
  • Phone: 847-982-3175
  • Fax: 847-982-3394

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number085011123
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: