Provider Demographics
NPI:1861830838
Name:MCKIDDY, CLAYTON EDWARD (ANP)
Entity type:Individual
Prefix:
First Name:CLAYTON
Middle Name:EDWARD
Last Name:MCKIDDY
Suffix:
Gender:M
Credentials:ANP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:670 MASON RIDGE CENTER DR
Mailing Address - Street 2:STE 300
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141-8573
Mailing Address - Country:US
Mailing Address - Phone:314-996-3434
Mailing Address - Fax:314-996-3595
Practice Address - Street 1:969 N MASON RD
Practice Address - Street 2:STE 160
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141-6338
Practice Address - Country:US
Practice Address - Phone:314-996-3434
Practice Address - Fax:314-996-3595
Is Sole Proprietor?:No
Enumeration Date:2013-06-12
Last Update Date:2013-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2013011243363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health