Healthcare Provider Details

I. General information

NPI: 1053321075
Provider Name (Legal Business Name): THOMAS ALI KIDD JR. PAC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/09/2006
Last Update Date: 04/07/2022
Certification Date: 04/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

190 CAMPUS BLVD SUITE 200
WINCHESTER VA
22601
US

IV. Provider business mailing address

PO BOX 1671
CUMBERLAND MD
21501-1671
US

V. Phone/Fax

Practice location:
  • Phone: 540-662-0306
  • Fax: 540-662-5845
Mailing address:
  • Phone: 240-964-8342
  • Fax: 240-964-8337

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberC0000621
License Number StateMD
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number1053
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: