Healthcare Provider Details

I. General information

NPI: 1538492509
Provider Name (Legal Business Name): CAROLYN RAE TIDD PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/09/2009
Last Update Date: 04/02/2025
Certification Date: 04/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2249 STATE ROUTE 86 STE 2
SARANAC LAKE NY
12983-5644
US

IV. Provider business mailing address

2249 STATE ROUTE 86 STE 2
SARANAC LAKE NY
12983-5644
US

V. Phone/Fax

Practice location:
  • Phone: 518-354-5353
  • Fax: 518-354-8153
Mailing address:
  • Phone: 518-354-5353
  • Fax: 518-354-8153

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number013307
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: