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General NPI Number Information
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NPI Number | 1114079878
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Entity Type | Individual
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Provider Name | DARREL SIDES CSA
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Gender | Male
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Dates
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Enumeration Date | 01/16/2007
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 6271 MARTYS TRAIL
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City | INDEPENDENCE
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State | KY
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Zip | 41051-0583
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Country | US
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Telephone | 859-816-6684
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Fax | 859-356-0682
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Provider Business Mailing Address
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Address Line | PO BOX 583
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City | INDEPENDENCE
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State | KY
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Zip | 41051-0583
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Country | US
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Telephone | 859-816-6684
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Fax | 859-356-0682
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363AS0400X
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Taxonomy Name | Surgical Physician Assistant
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License Number | SA109
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License Number State | KY
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