Provider Demographics
NPI:1356317580
Name:ELLIS, THOMAS KEVIN (CRNA)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:KEVIN
Last Name:ELLIS
Suffix:
Gender:M
Credentials:CRNA
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Other - First Name:
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Mailing Address - Street 1:8100 34TH AVE S
Mailing Address - Street 2:21110Q
Mailing Address - City:BLOOMINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:55425-1672
Mailing Address - Country:US
Mailing Address - Phone:952-883-7961
Mailing Address - Fax:952-883-5395
Practice Address - Street 1:640 JACKSON ST
Practice Address - Street 2:MAIL STOP 11503P
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55101-2502
Practice Address - Country:US
Practice Address - Phone:651-254-3456
Practice Address - Fax:651-254-3048
Is Sole Proprietor?:No
Enumeration Date:2006-02-27
Last Update Date:2014-12-31
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MNR0628291367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN437842300Medicaid
MN437842300Medicaid