Provider Demographics
NPI:1609614569
Name:SIDHU, KAMALDEEP
Entity type:Individual
Prefix:
First Name:KAMALDEEP
Middle Name:
Last Name:SIDHU
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:164 TURKEY HILL RD
Mailing Address - Street 2:
Mailing Address - City:RUTLAND
Mailing Address - State:MA
Mailing Address - Zip Code:01543-2256
Mailing Address - Country:US
Mailing Address - Phone:508-320-0362
Mailing Address - Fax:
Practice Address - Street 1:164 TURKEY HILL RD
Practice Address - Street 2:
Practice Address - City:RUTLAND
Practice Address - State:MA
Practice Address - Zip Code:01543-2256
Practice Address - Country:US
Practice Address - Phone:508-320-0362
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-16
Last Update Date:2024-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2023165393363LF0000X
MARN2358975363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily