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 1:773 STIRLING CENTER PL
Mailing Address - Street 2:
Mailing Address - City:LAKE MARY
Mailing Address - State:FL
Mailing Address - Zip Code:32746-4856
Mailing Address - Country:US
Mailing Address - Phone:407-977-4130
Mailing Address - Fax:407-977-4139
Practice Address - Street 1:773 STIRLING CENTER PL
Practice Address - Street 2:
Practice Address - City:LAKE MARY
Practice Address - State:FL
Practice Address - Zip Code:32746-4856
Practice Address - Country:US
Practice Address - Phone:407-977-4130
Practice Address - Fax:407-977-4139
Is Sole Proprietor?:No
Enumeration Date:2006-05-19
Last Update Date:2024-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE1029363A00000X, 363AM0700X, 363AS0400X
FLPA9113657363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NER78866Medicare UPIN
NE275744Medicare ID - Type Unspecified