Provider Demographics
NPI:1255663670
Name:THOMAS, KELLY JOE (BS MT(ASCP) CLS(NCA))
Entity Type:Individual
Prefix:MR
First Name:KELLY
Middle Name:JOE
Last Name:THOMAS
Suffix:
Gender:M
Credentials:BS MT(ASCP) CLS(NCA)
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3200 CANYON LAKE DR
Mailing Address - Street 2:
Mailing Address - City:RAPID CITY
Mailing Address - State:SD
Mailing Address - Zip Code:57702-8114
Mailing Address - Country:US
Mailing Address - Phone:605-355-2229
Mailing Address - Fax:605-355-2514
Practice Address - Street 1:3200 CANYON LAKE DR
Practice Address - Street 2:
Practice Address - City:RAPID CITY
Practice Address - State:SD
Practice Address - Zip Code:57702-8114
Practice Address - Country:US
Practice Address - Phone:605-355-2229
Practice Address - Fax:305-355-2514
Is Sole Proprietor?:No
Enumeration Date:2010-02-10
Last Update Date:2010-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
204742246QM0706X
206256246QM0706X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246QM0706XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, PathologyMedical Technologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD0140070Medicaid
SD5549050OtherMEDICAID
SDHSZ050Medicare PIN
SDPHS000Medicare UPIN
SD430082Medicare Oscar/Certification