Healthcare Provider Details

I. General information

NPI: 1093939183
Provider Name (Legal Business Name): JASON S. KIDD PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/12/2007
Last Update Date: 07/16/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

924 LIBERTY STREET
WEST MILFORD WV
26451
US

IV. Provider business mailing address

PO BOX 217
ROCK CAVE WV
26234-0217
US

V. Phone/Fax

Practice location:
  • Phone: 304-745-4568
  • Fax: 304-326-3700
Mailing address:
  • Phone: 304-924-6262
  • Fax: 304-924-5460

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number01023
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: