Provider Demographics
NPI:1376859470
Name:KLVANA, THOMAS LESTER (PA)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:LESTER
Last Name:KLVANA
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 E HOSPITAL ST
Mailing Address - Street 2:HOSPITALIST DEPARTMENT
Mailing Address - City:MANNING
Mailing Address - State:SC
Mailing Address - Zip Code:29102-3153
Mailing Address - Country:US
Mailing Address - Phone:803-435-8463
Mailing Address - Fax:803-435-5288
Practice Address - Street 1:10 E HOSPITAL ST
Practice Address - Street 2:HOSPITALIST DEPARTMENT
Practice Address - City:MANNING
Practice Address - State:SC
Practice Address - Zip Code:29102-3153
Practice Address - Country:US
Practice Address - Phone:803-435-8463
Practice Address - Fax:803-435-5288
Is Sole Proprietor?:No
Enumeration Date:2010-08-26
Last Update Date:2014-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCTL 1546363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCTL 1546OtherPA LICENSE
SCAA61409485Medicare PIN