Healthcare Provider Details

I. General information

NPI: 1780637504
Provider Name (Legal Business Name): KELLI K THOMAZIN PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/19/2006
Last Update Date: 11/07/2024
Certification Date: 11/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

773 STIRLING CENTER PL
LAKE MARY FL
32746-4856
US

IV. Provider business mailing address

773 STIRLING CENTER PL
LAKE MARY FL
32746-4856
US

V. Phone/Fax

Practice location:
  • Phone: 407-977-4130
  • Fax: 407-977-4139
Mailing address:
  • Phone: 407-977-4130
  • Fax: 407-977-4139

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number1029
License Number StateNE
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number1029
License Number StateNE
# 3
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number1029
License Number StateNE
# 4
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberPA9113657
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: