Provider Demographics
NPI:1548200041
Name:THOM, KRISTIN I (DO)
Entity Type:Individual
Prefix:DR
First Name:KRISTIN
Middle Name:I
Last Name:THOM
Suffix:
Gender:F
Credentials:DO
Other - Prefix:DR
Other - First Name:KRISTIN
Other - Middle Name:IT
Other - Last Name:MCDERMOTT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:2318 E CENTRAL AVE STE 300
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67214-4436
Mailing Address - Country:US
Mailing Address - Phone:316-262-2415
Mailing Address - Fax:316-264-4734
Practice Address - Street 1:527 N GROVE ST
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67214-4520
Practice Address - Country:US
Practice Address - Phone:316-262-2415
Practice Address - Fax:316-264-4734
Is Sole Proprietor?:No
Enumeration Date:2006-06-07
Last Update Date:2019-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME1704207Q00000X
KS05-40309207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME333070099Medicaid
MEMM947801Medicare PIN
ME333070099Medicaid
H65143Medicare UPIN