Basic Information
| Provider Information | |||||||||
| NPI: | 1760731590 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SIDHU | ||||||||
| FirstName: | VIRINDER | ||||||||
| MiddleName: | |||||||||
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| Credential: | ACNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 103 MCKNIGHT DR | ||||||||
| Address2: | SUITE A | ||||||||
| City: | MIDDLETOWN | ||||||||
| State: | OH | ||||||||
| PostalCode: | 450444890 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5132176400 | ||||||||
| FaxNumber: | 5132176037 | ||||||||
| Practice Location | |||||||||
| Address1: | 103 MCKNIGHT DR | ||||||||
| Address2: | SUITE A | ||||||||
| City: | MIDDLETOWN | ||||||||
| State: | OH | ||||||||
| PostalCode: | 450444890 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5132176400 | ||||||||
| FaxNumber: | 5132176037 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/07/2012 | ||||||||
| LastUpdateDate: | 03/17/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | RN.333035 | OH | N | Nursing Service Providers | Registered Nurse | 363LA2100X | NP13909 | OH | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Acute Care |
ID Information
| ID | Type | State | Issuer | Description | 0074909 | 05 | OH | MEDICAID |