Active NPI
Darrel Sides, CSA
- Surgical Physician Assistant
- Independence, KY
National Provider Identifier
1114079878
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Surgical Physician Assistant
- License
- SA109
- Practice address
- 6271 Martys Trail
Independence, KY 41051-0583 - Phone
- (859) 816-6684
- Fax
- (859) 356-0682
- NPI assigned
- Jan 16, 2007
- Sex
- Male
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Surgical Physician Assistant | 363AS0400X | SA109 | KY | Primary |
Addresses
Primary practice location
6271 Martys Trail
Independence, KY 41051-0583
Mailing address
PO Box 583
Independence, KY 41051-0583
Phone (859) 816-6684
Other identifiers 1
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 000000308821 | Other | KY | BC |
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| SA109 | KY | MD | Surgical Physician Assistant |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1168905600000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1183852800000",
"number": "1114079878",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "PO BOX 583",
"city": "INDEPENDENCE",
"state": "KY",
"postal_code": "410510583",
"telephone_number": "859-816-6684",
"fax_number": "859-356-0682"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "6271 MARTYS TRAIL",
"city": "INDEPENDENCE",
"state": "KY",
"postal_code": "410510583",
"telephone_number": "859-816-6684",
"fax_number": "859-356-0682"
}
],
"practiceLocations": [],
"basic": {
"last_name": "SIDES",
"first_name": "DARREL",
"name_prefix": "Mr.",
"credential": "CSA",
"sole_proprietor": "NO",
"sex": "M",
"enumeration_date": "2007-01-16",
"last_updated": "2007-07-08",
"status": "A"
},
"taxonomies": [
{
"code": "363AS0400X",
"taxonomy_group": "",
"desc": "Physician Assistant, Surgical",
"state": "KY",
"license": "SA109",
"primary": true
}
],
"identifiers": [
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "BC",
"identifier": "000000308821",
"state": "KY"
}
],
"endpoints": [],
"other_names": []
}Other providers in Independence, KY
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 8, 2007; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.