Provider Demographics
NPI:1104905751
Name:SIDERS, KIMBERLY BETH (PA-C)
Entity type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:BETH
Last Name:SIDERS
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Gender:F
Credentials:PA-C
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Mailing Address - Street 1:15051 S TAMIAMI TRL
Mailing Address - Street 2:SUITE 203
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33908-5182
Mailing Address - Country:US
Mailing Address - Phone:239-437-8810
Mailing Address - Fax:239-313-2555
Practice Address - Street 1:15310 AMBERLY DR
Practice Address - Street 2:SUITE 150
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33647-2199
Practice Address - Country:US
Practice Address - Phone:813-978-8888
Practice Address - Fax:813-972-8974
Is Sole Proprietor?:No
Enumeration Date:2006-11-03
Last Update Date:2017-03-10
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
FLPA9103918363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLAD578YMedicare PIN