Basic Information
| Provider Information | |||||||||
| NPI: | 1407929771 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KIDD | ||||||||
| FirstName: | DEBRA | ||||||||
| MiddleName: | KAY | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 300 E MCBEE AVE FL 4 | ||||||||
| Address2: | |||||||||
| City: | GREENVILLE | ||||||||
| State: | SC | ||||||||
| PostalCode: | 296012842 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8645228603 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 7 INDEPENDENCE PT STE 300 | ||||||||
| Address2: | |||||||||
| City: | GREENVILLE | ||||||||
| State: | SC | ||||||||
| PostalCode: | 296154569 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8645223700 | ||||||||
| FaxNumber: | 8645223705 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/16/2006 | ||||||||
| LastUpdateDate: | 12/28/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 12/28/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | 48340 | WV | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered | 367500000X | COA.09620-NA | OH | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered | 367500000X | 1462 | SC | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 000000644238 | 01 | OH | ANTHEM | OTHER | AN0931 | 05 | SC | MEDICAID | 2603159000 | 05 | WV | MEDICAID | 000000573847 | 01 | OH | ANTHEM | OTHER | 260315900 | 05 | WV | MEDICAID | P00703818 | 01 | OH | RRMCR | OTHER | 2884080 | 05 | OH | MEDICAID |