Provider Demographics
NPI:1124084090
Name:KIDDER, MAXINE (PNP)
Entity type:Individual
Prefix:
First Name:MAXINE
Middle Name:
Last Name:KIDDER
Suffix:
Gender:F
Credentials:PNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:139 PROFESSIONAL PKWY
Mailing Address - Street 2:
Mailing Address - City:LOCKPORT
Mailing Address - State:NY
Mailing Address - Zip Code:14094-5369
Mailing Address - Country:US
Mailing Address - Phone:716-433-6711
Mailing Address - Fax:716-433-0546
Practice Address - Street 1:139 PROFESSIONAL PKWY
Practice Address - Street 2:
Practice Address - City:LOCKPORT
Practice Address - State:NY
Practice Address - Zip Code:14094-5369
Practice Address - Country:US
Practice Address - Phone:716-433-6711
Practice Address - Fax:716-433-0546
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY380525363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY000560073003OtherBLUE CROSS/BLUE SHIELD
NY9512424OtherINDEPENDENT HEALTH
NY01400724Medicaid