Provider Demographics
NPI:1780637504
Name:THOMAZIN, KELLI K (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:KELLI
Middle Name:K
Last Name:THOMAZIN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4508 38TH ST
Mailing Address - Street 2:SUITE 133
Mailing Address - City:COLUMBUS
Mailing Address - State:NE
Mailing Address - Zip Code:68601-1668
Mailing Address - Country:US
Mailing Address - Phone:402-563-3644
Mailing Address - Fax:402-564-5805
Practice Address - Street 1:4508 38TH ST
Practice Address - Street 2:SUITE 133
Practice Address - City:COLUMBUS
Practice Address - State:NE
Practice Address - Zip Code:68601-1668
Practice Address - Country:US
Practice Address - Phone:402-563-3644
Practice Address - Fax:402-564-5805
Is Sole Proprietor?:No
Enumeration Date:2006-05-19
Last Update Date:2010-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE1029363AM0700X, 363AS0400X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NER78866Medicare UPIN
NE275744Medicare ID - Type Unspecified