Basic Information
| Provider Information | |||||||||
| NPI: | 1144326737 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KLOTT | ||||||||
| FirstName: | VIDA | ||||||||
| MiddleName: | HB | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | MPAS, PAC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 500 KIRTS BLVD STE 100 | ||||||||
| Address2: | |||||||||
| City: | TROY | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480844135 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2484346169 | ||||||||
| FaxNumber: | 8556186655 | ||||||||
| Practice Location | |||||||||
| Address1: | 2205 JOLLY RD STE B | ||||||||
| Address2: | |||||||||
| City: | OKEMOS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 488643983 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5173474085 | ||||||||
| FaxNumber: | 5173474170 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/15/2006 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 5601004563 | MI | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 0N77190 | 01 | MI | GROUP MEDICARE PIN | OTHER | N77190003 | 01 | MI | MEDICARE PIN | OTHER |