Provider Demographics
NPI:1386997229
Name:KIDD, CLYDE L (PA-C)
Entity type:Individual
Prefix:
First Name:CLYDE
Middle Name:L
Last Name:KIDD
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2360 MULLAN RD STE C
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59808-1811
Mailing Address - Country:US
Mailing Address - Phone:406-721-4436
Mailing Address - Fax:406-721-6053
Practice Address - Street 1:2360 MULLAN RD STE C
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59808-1811
Practice Address - Country:US
Practice Address - Phone:406-721-4436
Practice Address - Fax:406-721-6053
Is Sole Proprietor?:No
Enumeration Date:2012-10-16
Last Update Date:2012-10-16
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MT20186363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant