=====================================================
General NPI Number Information
=====================================================
NPI Number | 1659525681
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KENNETH EDWARD NIDA P.A.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/04/2008
-----------------------------------------------------
Last Update Date | 06/08/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 320 N CLYDE MORRIS BLVD
-----------------------------------------------------
City | DAYTONA BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32114-2744
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 386-238-3293
-----------------------------------------------------
Fax | 386-238-3223
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 9671
-----------------------------------------------------
City | DAYTONA BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32120-9671
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 386-676-7130
-----------------------------------------------------
Fax | 386-676-7125
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number | PA 9107756
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------